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 B
Explanation
The correct answer is choice B.
Choice A rationale:
Vitamin K is given to newborns to prevent bleeding disorders, not eye conditions.
Choice B rationale:
Erythromycin ophthalmic ointment is commonly used for prophylaxis of neonatal conjunctivitis (pink eye) caused by Neisseria gonorrhoeae and Chlamydia trachomatis.
Choice C rationale:
Gentamicin ophthalmic ointment can be used to treat bacterial infections of the eye, but it is not typically used for prophylaxis of neonatal eye conditions.
Choice D rationale:
Silver nitrate solution was once used for prophylaxis of neonatal eye conditions, but it is no longer commonly used due to the risk of chemical conjunctivitis.
Correct Answer is B
Explanation
The correct answer is choice B.
Choice A rationale:
Stimulating the infant to cry is important, but it is not the first action to be taken.
Choice B rationale:
Clearing the respiratory tract is the first action to be taken to ensure the newborn can breathe properly.
Choice C rationale:
Drying the infant off and covering the head is done after the respiratory tract is cleared.
Choice D rationale:
Cutting the umbilical cord is done after the infant is stabilized.
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