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 D
Explanation
Choice A rationale
Wound infection usually presents with redness, warmth, and swelling, not just yellow exudate. The presence of yellow exudate alone typically does not indicate an infection.
Choice B rationale
Ulceration would involve the breakdown of skin or tissue, which is not indicated by the presence of yellow exudate. Ulcerations are more severe and painful than normal post-
circumcision healing.
Choice C rationale
Exposure to urine can cause irritation but does not typically result in yellow exudate. Proper diapering and cleaning prevent this irritation, and exudate is part of the healing process,
not a result of urine exposure.
Choice D rationale
Healing is indicated by the presence of yellow exudate, which is a normal part of the healing process post-circumcision. It signifies that the glans is recovering as expected. .
Correct Answer is A
Explanation
Choice A rationale
Music can be a non-pharmacological method to help manage pain and anxiety during the latent phase of labor.
Choice B rationale
Biofeedback might be helpful but can be challenging to implement without prior training.
Choice C rationale
Administering fentanyl 100 mg every hour is not appropriate; fentanyl is typically administered in much smaller doses.
Choice D rationale
A pudendal nerve block is usually reserved for the second stage of labor or delivery, not the latent phase.