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.
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Correct Answer is B
Explanation
Choice A rationale
During labor, the body experiences physiological stress, which typically causes an increase, not a decrease, in white blood cell (WBC) count. This increase is a normal response to stress.
Choice B rationale
Blood glucose levels can decrease during labor due to the energy expenditure and physiological demands of the process. This is why it is important to monitor glucose levels and provide necessary interventions if hypoglycemia occurs.
Choice C rationale
The respiratory rate generally increases during labor to meet the increased oxygen demands of the body. A decrease in respiratory rate is not expected during this time.
Choice D rationale
Body temperature may increase slightly during labor due to the physical exertion and metabolic activity involved. A decrease in temperature is not a typical finding during labor.
Correct Answer is B
Explanation
Choice A rationale
A positive pregnancy test is a probable sign of pregnancy as it indicates the presence of hCG, a hormone produced during pregnancy. However, it is not a presumptive sign, as other
conditions can also result in elevated hCG levels.
Choice B rationale
Amenorrhea, or the absence of menstrual periods, is a presumptive sign of pregnancy. It is one of the earliest indications that a woman may be pregnant, though it can also be
caused by other factors such as stress or hormonal imbalances.
Choice C rationale
Fetal heart sounds detected by Doppler ultrasound are a positive sign of pregnancy, confirming the presence of a fetus. This is not a presumptive sign as it is direct evidence of
pregnancy.
Choice D rationale
Chadwick's sign, a bluish discoloration of the cervix, vagina, and labia due to increased blood flow, is considered a probable sign of pregnancy. It is not a presumptive sign but rather
a physical change that occurs during pregnancy. .