When reviewing the medical record of a postpartum client, the nurse notes that the client has experienced a fourth-degree laceration.
The nurse understands that the laceration extends to which area?.
Superficial structures above the muscle.
Through the anterior rectal wall.
Through the anal sphincter muscle.
Through the perineal muscles.
The Correct Answer is D
The correct answer is choice D.
Choice A rationale:
Superficial structures above the muscle refer to first-degree lacerations, which only involve the skin of the perineum and vaginal mucosa.
Choice B rationale:
A fourth-degree laceration does not stop at the anterior rectal wall. It extends through the anal sphincter and into the rectal mucosa.
Choice C rationale:
While a fourth-degree laceration does involve the anal sphincter muscle, it also includes the underlying rectal mucosa.
Choice D rationale:
A fourth-degree laceration involves the perineal muscles, the anal sphincter, and the underlying rectal mucosa.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C.
Choice A rationale:
Generalized vasospasm is not a symptom of abruptio placenta. It is more associated with conditions like preeclampsia.
Choice B rationale:
Abruptio placenta is usually associated with painful dark red vaginal bleeding, not painless bright red bleeding.
Choice C rationale:
“Knife-like” abdominal pain with vaginal bleeding is a classic symptom of abruptio placenta.
Choice D rationale:
Increased fetal movement is not a symptom of abruptio placenta. In fact, fetal movement may decrease due to distress.
Correct Answer is D
Explanation
The correct answer is choice D.
Choice A rationale:
While antidepressants can be an effective treatment for postpartum depression, it is not the priority action. The priority is to ensure the safety of the mother and the baby.
Choice B rationale:
Reinforcing postpartum and newborn care discharge teaching is important, but it is not the priority action when a client is showing signs of postpartum depression.
Choice C rationale:
Assisting the family to identify prior use of positive coping skills in family crises can be helpful, but it is not the priority action when a client is showing signs of postpartum depression.
Choice D rationale:
The priority action when a client is showing signs of postpartum depression is to assess for suicidal ideation or thoughts of harming herself or her baby. This is because postpartum depression can lead to thoughts of self-harm or harm to the baby, and immediate intervention is necessary to ensure the safety of both the mother and the baby.
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