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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View Related questions
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
Variable decelerations are associated with umbilical cord compression, not placenta previa. In placenta previa, the placenta covers the cervical os, but it does not typically cause
variable decelerations on fetal monitoring.
Choice B rationale
Painless vaginal bleeding is a hallmark sign of placenta previa. This occurs because the placenta is located near or over the cervical os, leading to bleeding when the cervix dilates
or effaces.
Choice C rationale
A rigid abdomen is more indicative of placental abruption, where the placenta detaches prematurely from the uterine wall, causing pain and a tense abdomen, not typically seen in
placenta previa.
Choice D rationale
Uterine tachysystole is characterized by excessive uterine contractions and is not a clinical finding related to placenta previa. Tachysystole often results from excessive oxytocin use
or other uterine stimulants.