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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

The correct answer is choice A. She did her perineal care independently.

Choice A rationale:

Taking the initiative for caring for her newborn independently while managing her own postpartum needs marks the taking-hold phase of infant bonding.

Choice B rationale:

Being eager to talk about her birth experience is more associated with the taking-in phase, not the taking-hold phase.

Choice C rationale:

Not asking for anything for pain all day is not a specific indicator of the taking-hold phase.

Choice D rationale:

Sitting and rocking her infant for long intervals is not a specific indicator of the taking-hold phase.

A. "This could result in profound bleeding.” B. "There is an increased risk of introducing infection.” C. "This could initiate preterm labor.” D. "There is an increased risk of rupture of the amniotic membranes.”.

Correct Answer is A

Explanation

The correct answer is choice A.

Choice A rationale:

An internal examination could disturb the placenta and cause profound bleeding, which is a life-threatening condition for both the mother and the fetus.

Choice B rationale:

While there is always a risk of introducing infection during an internal examination, this is not the primary reason to avoid it in a client with placenta previa.

Choice C rationale:

An internal examination could potentially initiate preterm labor, but this is not the primary concern with placenta previa.

Choice D rationale:

While there is a risk of rupture of the amniotic membranes during an internal examination, this is not the primary reason to avoid it in a client with placenta previa.

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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?.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a postpartum woman.Which behavior would the nurse interpret as an indication that the woman is entering the taking-hold phase of the postpartum period?

Correct Answer is A

Explanation

A nurse is caring for a client who is at 37 weeks of gestation and has placenta previa.The client asks the nurse why the provider does not do an internal examination.Which of the following explanations of the primary reason should the nurse provide?

Correct Answer is A

Explanation

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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?.