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 C

Explanation

The correct answer is choice C.

Choice A rationale:

Keeping the baby’s head covered helps to prevent heat loss, as newborns lose a significant amount of heat through their heads.

Choice B rationale:

Keeping the baby’s bassinet away from fans and air conditioning helps to maintain a stable body temperature.

Choice C rationale:

Newborns’ temperatures are typically checked every 3 to 4 hours, not every hour, and are usually done axillary, not rectally.

Choice D rationale:

Placing the baby on the mother’s stomach and covering her with a warm blanket promotes skin-to-skin contact and helps to maintain the baby’s body temperature.

A. Notify the client's provider. B. Increase the frequency of fundal massage. C. Document the findings and continue to monitor the client. D. Encourage the client to empty her bladder.

Correct Answer is C

Explanation

The correct answer is choice C.

Choice A rationale:

Notifying the provider is not necessary in this case as the findings are normal for a client who is 1 hour postpartum.

Choice B rationale:

Increasing the frequency of fundal massage is not necessary as the fundus is firm and at the umbilicus.

Choice C rationale:

The findings are normal for a client who is 1 hour postpartum. The nurse should document the findings and continue to monitor the client. Therefore, this choice is correct.

Choice D rationale:

Encouraging the client to empty her bladder is not necessary in this case as the fundus is midline.

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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 providing teaching about newborn care to a client who is 2 hr postpartum.Which of the following statements by the client indicates a need for further teaching?

Correct Answer is C

Explanation

A nurse is caring for a client who is 1 hr postpartum and observes a large amount of lochia rubra and several small clots on the client's perineal pad.The fundus is midline and firm at the umbilicus.Which of the following actions should the nurse take?.

Correct Answer is C

Explanation

A nurse is caring for a client who gave birth 2 hr ago.The nurse notes that the client's blood pressure is 60/50 mm Hg. Which of the following actions should the nurse take first?.

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A nurse is caring for a client who is postpartum and has a prescription for Rho (D) immunoglobulin.The nurse should verify which of the following prior to administration?.

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A client in the third stage of labor has experienced placental separation and expulsion.Why is it necessary for a nurse to massage the woman's uterus briefly until it is firm?.

A nurse is caring for a client on the second day postpartum.The client informs the nurse that she is voiding a large volume of urine frequently.Which factor should the nurse identify as a potential cause for urinary frequency?.

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?.