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 C
Explanation
The correct answer is choice C.
Choice A rationale:
While it’s important to monitor a newborn’s glucose level, it’s not the immediate priority following birth.
Choice B rationale:
Placing the infant in the bassinet is not the immediate priority. The newborn needs to be dried and warmed first to prevent hypothermia.
Choice C rationale:
Drying the newborn and placing it skin-to-skin on the mother helps prevent hypothermia and promotes bonding. This is the immediate priority.
Choice D rationale:
A full head-to-toe assessment is important, but it’s not the immediate priority following birth.
Correct Answer is C
Explanation
The correct answer is choice C.
Choice A rationale:
Sitz baths cause perineal vasodilation, not vasoconstriction, and this does not directly affect bleeding.
Choice B rationale:
The duration of a sitz bath does not necessarily correlate with its therapeutic effect.
Choice C rationale:
Sitz baths increase the blood supply to the perineal area, promoting healing and providing relief from discomfort.
Choice D rationale:
Sitz baths do not increase the risk of postpartum infection when done properly.
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