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 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.

A. Sitz baths cause perineal vasoconstriction and decreased bleeding. B. The longer a sitz bath is continued, the more therapeutic it becomes. C. Sitz baths increase the blood supply to the perineal area. D. Sitz baths may lead to increased postpartum infection.

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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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

Which action would be a priority for the nurse to complete immediately after the delivery of a 40-week gestation newborn?.

Correct Answer is C

Explanation

Which information would the nurse emphasize in the teaching plan for a postpartum woman who is reluctant to begin taking warm sitz baths?

Correct Answer is C

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.

The nurse is preparing a teaching plan for a pregnant woman about the signs and symptoms to be reported immediately to her health care provider.Which signs and symptoms would the nurse include? Select all that apply.

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?

A nurse in a clinic is caring for a client who is 3 weeks postpartum following the birth of a healthy newborn.The client reports feeling "down" and sad, having no energy, and wanting to cry.Which of the following is a priority action by the nurse?.

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A nurse determines that a newborn has a 1-minute Apgar score of 5 points.What conclusion would the nurse make from this finding?.

At what time is the laboring client encouraged to push?

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?.