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:
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.
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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