A nurse is reinforcing teaching with a client who is in labor about an episiotomy. Which of the following information should the nurse include?

An episiotomy is an incision that is made by the provider to facilitate delivery of the fetus.

An episiotomy is a perineal tear that is created while pushing during labor.

A mediolateral episiotomy is easier to repair than a median episiotomy

A fourth-degree episiotomy is always needed.

Answer and Explanation

The Correct Answer is A

A. An episiotomy is an incision that is made by the provider to facilitate delivery of the fetus. An episiotomy is a surgical incision made in the perineum to enlarge the vaginal opening for delivery and reduce the risk of severe perineal tearing.

B. An episiotomy is a perineal tear that is created while pushing during labor. An episiotomy is an intentional incision, while a perineal tear is an unplanned, spontaneous laceration that occurs during pushing.

C. A mediolateral episiotomy is easier to repair than a median episiotomy. A median episiotomy is typically easier to repair and has less associated pain than a mediolateral incision, which is made at an angle.

D. A fourth-degree episiotomy is always needed. A fourth-degree episiotomy, which extends through the rectal mucosa, is rarely performed and is not always needed. Most episiotomies are less severe.

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Correct Answer is B

Explanation

A. Take the client's temperature. Monitoring the client's temperature for signs of infection is important, but it is not the priority immediately following an amniotomy. Infection typically develops over time.

B. Check the fetal heart rate pattern. The priority after an amniotomy is to assess the fetal heart rate to detect any signs of umbilical cord prolapse or fetal distress, which can occur immediately after rupture of membranes.

C. Observe the color and consistency of amniotic fluid. Although it is important to observe amniotic fluid for abnormalities (e.g., meconium staining), the immediate priority is fetal heart rate monitoring.

D. Evaluate the client for signs of infection. Signs of infection should be monitored, but they are not the priority right after amniotomy.

A. "This is a cephalhematoma, which will resolve on its own in 3 to 5 days." B. "This is a caput succedaneum, which is a collection of fluid from pressure of the vacuum extractor." C. "This is erythema toxicum, which is a transient allergic reaction that causes edema in the skin." D. "This is a Mongolian spot, which is found on many newborns."

Correct Answer is B

Explanation

A. "This is a cephalhematoma, which will resolve on its own in 3 to 5 days." A cephalhematoma is a collection of blood between the skull bone and periosteum, and it does not cross suture lines. Caput succedaneum, on the other hand, does cross suture lines.

B. "This is a caput succedaneum, which is a collection of fluid from pressure of the vacuum extractor." Caput succedaneum is swelling of the soft tissues of the scalp caused by pressure during birth, especially with vacuum extraction, and it crosses suture lines.

C. "This is erythema toxicum, which is a transient allergic reaction that causes edema in the skin." Erythema toxicum is a common newborn rash, but it does not cause swelling on the head or cross suture lines.

D. "This is a Mongolian spot, which is found on many newborns." Mongolian spots are bluish-gray marks usually found on the lower back or buttocks, not on the head, and they are not related to vacuum extraction or swelling.

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A nurse is reinforcing teaching with a client who is in labor about an episiotomy. Which of the following information should the nurse include?

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Naxlex Comprehensive Predictor Exams

A nurse is assisting in the care of a client who is to undergo an amniotomy. Which of the following is the priority nursing action following this procedure?

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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