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 B

Explanation

The correct answer is choice B.

Choice A rationale:

Cabbage leaves have been used for many years for relief of breast engorgement. They can be crushed slightly until the juice is visible and then chilled in the refrigerator before applying to the breasts.

Choice B rationale:

Applying hot packs during feeding can actually increase blood flow and make engorgement worse. Cold packs should be used after feeding to help reduce swelling.

Choice C rationale:

Applying ice packs after feeding can help reduce swelling and provide relief from engorgement.

Choice D rationale:

Frequent breastfeeding can help to relieve engorgement. The breasts should be emptied completely at each feeding.

A. "This could result in profound bleeding.” B. "There is an increased risk of introducing infection.” C. "This could initiate preterm labor.” D. "There is an increased risk of rupture of the amniotic membranes.”.

Correct Answer is A

Explanation

The correct answer is choice A.

Choice A rationale:

An internal examination could disturb the placenta and cause profound bleeding, which is a life-threatening condition for both the mother and the fetus.

Choice B rationale:

While there is always a risk of introducing infection during an internal examination, this is not the primary reason to avoid it in a client with placenta previa.

Choice C rationale:

An internal examination could potentially initiate preterm labor, but this is not the primary concern with placenta previa.

Choice D rationale:

While there is a risk of rupture of the amniotic membranes during an internal examination, this is not the primary reason to avoid it in a client with placenta previa.

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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 comfort measures for breast engorgement to a client who is postpartum and is breastfeeding.Which of the following statements by the client indicates a need for further teaching?.

Correct Answer is B

Explanation

A nurse is caring for a client who is at 37 weeks of gestation and has placenta previa.The client asks the nurse why the provider does not do an internal examination.Which of the following explanations of the primary reason should the nurse provide?

Correct Answer is A

Explanation

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?.

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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?.