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 D
Explanation
The correct answer is choice D. When the cervix is fully dilated.
Choice A rationale:
The arrival of the health care provider does not determine when the laboring client should push. This is dependent on the dilation of the cervix.
Choice B rationale:
Seeing the fetal head is not the determinant for when the laboring client should push. The cervix needs to be fully dilated.
Choice C rationale:
The nurse wanting the client to push is not the correct time for the laboring client to push. The cervix needs to be fully dilated.
Choice D rationale:
The laboring client is encouraged to push when the cervix is fully dilated. This is to avoid birth trauma.
Correct Answer is B
Explanation
The correct answer is choice B.
Choice A rationale:
Abdominal pain with scant red vaginal bleeding is more indicative of placental abruption, not placenta previa.
Choice B rationale:
Painless red vaginal bleeding is a classic sign of placenta previa. This happens because the placenta is covering the cervix, which can lead to bleeding.
Choice C rationale:
Increasing abdominal pain with a nonrelaxed uterus is more indicative of a condition like uterine rupture or labor, not placenta previa.
Choice D rationale:
Intermittent abdominal pain following the passage of bloody mucus is more likely a sign of labor, not placenta previa.
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