The nurse is caring for a postpartum client who is complaining of severe pain and a feeling of pressure in her perineum. Her fundus is firm and she has a moderate lochial flow. On inspection, the nurse finds that a perineal hematoma is beginning to form. Which assessment finding should the nurse obtain first?
Hemoglobin and hematocrit
Abdominal contour and bowel sounds
Heart rate and blood pressure
Urinary output and IV fluid intake
The Correct Answer is C
A. Hemoglobin and hematocrit:
While monitoring hemoglobin and hematocrit levels is important for assessing blood loss, in the immediate situation of a developing perineal hematoma with severe pain and pressure, assessing vital signs takes precedence to identify any signs of circulatory compromise.
B. Abdominal contour and bowel sounds:
These assessments are not the first priority in this situation. The client's complaint of severe pain and pressure in the perineum indicates a localized issue that needs immediate attention.
C. Heart rate and blood pressure:
This is the correct answer. Assessing the client's heart rate and blood pressure is crucial to identify signs of shock or compromised circulation associated with the perineal hematoma.
D. Urinary output and IV fluid intake:
While monitoring urinary output and IV fluid intake is important for overall assessment, in the context of a perineal hematoma, assessing vital signs is more immediate to identify any signs of hemodynamic instability.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Use a fingertip to palpate the inguinal canal for a weakening or indentation:
This is a reasonable next step in assessing for undescended testes. Palpating the inguinal canal can help determine if the testes are located in the inguinal area.
B.Measure the size of the scrotal sac for length and width:
While scrotal size can be relevant in some contexts, it may not provide direct information about the presence or absence of the testes. Palpation or other methods are more specific for this purpose.
C. Perform transillumination of the scrotal sac to visualize shadows of the testes:
Transillumination involves shining light through tissues to detect structures. However, in the case of evaluating the presence of testes, palpation is usually a more direct and accurate method.
D. Observe the urethral opening on the surface of the penis when the newborn voids:
This option is unrelated to assessing the presence of testes. Observing the urethral opening is more relevant for assessing the anatomy of the penis.
Correct Answer is D
Explanation
A. Epidural block: Epidural anesthesia is a regional anesthesia that blocks sensations in a specific region of the body. It is commonly used in labor and delivery to provide pain relief by injecting anesthetic medication into the epidural space, numbing the lower half of the body.
B. Saddle block: A saddle block, also known as a subarachnoid block, is a type of spinal anesthesia. It involves injecting anesthetic medication into the subarachnoid space, providing numbness to the lower half of the body, including the perineum.
C. Paracervical block: A paracervical block involves injecting a local anesthetic around the cervix. It is used to provide pain relief during certain medical procedures, such as cervical dilation or biopsy. It does not provide anesthesia to the entire perineum.
D. Pudendal block: A pudendal block involves injecting a local anesthetic into the pudendal nerve, which supplies sensation to the perineum. It is often used during the second stage of labor to provide localized pain relief during the delivery of the baby's head.
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