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. Active herpes simplex infection. B. Chronic cocaine use. C. Folic acid deficiency. D. Chronic alcohol use. E. Folic acid deficiency.

Correct Answer is D

No 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?.

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 woman gives birth to a small infant with a malformed skull. The infant grows abnormally slowly and shows signs of substantial cognitive and intellectual deficits. The child also has facial abnormalities including a short nose and thin lip that become more striking as it develops.

Correct Answer is D

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The Apgar score is based on which 5 parameters?.

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A nurse is caring for a client who just delivered a newborn.Following the delivery, which nursing action should be done first to care for the newborn?

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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?.