A nurse is caring for a client who had a vaginal delivery 2 hr ago and is reporting increasing perineal pain and pressure. The nurse examines the client's perineum and sees a 4 cm (1.6 in) area of purplish discoloration with swelling. The nurse should interpret these findings as which of the following?
A hematoma.
Retained placental fragments.
A laceration.
Ecchymosis.
Ecchymosis.
The Correct Answer is A
Choice A rationale
A hematoma presents as a localized collection of blood outside the blood vessels, causing a purplish discoloration and swelling, often resulting from trauma during delivery.
Choice B rationale
Retained placental fragments may cause postpartum hemorrhage and infection but would not present as a localized purplish swelling on the perineum.
Choice C rationale
A laceration would involve a tear in the tissue, causing bleeding and pain, but not necessarily a purplish discoloration with localized swelling unless associated with a hematoma.
Choice D rationale
Ecchymosis refers to bruising but is typically a more diffuse discoloration rather than a localized swelling and purplish area as seen with a hematoma.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is B
Explanation
Choice A rationale
Elevated BUN levels (25 mg/dL) can indicate kidney dysfunction, dehydration, or high protein intake. However, it’s not directly related to a prenatal complication, though it still
requires monitoring.
Choice B rationale
Hemoglobin (Hgb) of 10.2 mg/dL is below the normal range (11 to 16 mg/dL) and can indicate anemia. During pregnancy, anemia can lead to serious complications such as preterm
birth and low birth weight, making this result significant.
Choice C rationale
A fasting blood glucose level of 70 mg/dL falls within the normal range (70 to 110 mg/dL) and does not indicate a complication. Thus, it is not concerning in the context of prenatal
complications.
Choice D rationale
Hematocrit (Hct) of 32% is slightly below the normal range (33 to 47%), which can be common in pregnancy due to increased plasma volume. While monitoring is required, it’s not as
critical as anemia.
Correct Answer is B
Explanation
Choice A rationale
Meconium stools are common in newborns and not a concern in the context of weight loss.
Choice B rationale
Depressed fontanels can indicate dehydration in a newborn, which is critical, especially with significant weight loss.
Choice C rationale
Rust-stained urine is often due to urate crystals and is typical in newborns, not specifically alarming.
Choice D rationale
Overlapping suture lines can be a normal finding in a newborn's head and not indicative of an acute problem relating to weight loss.