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
Holding the newborn during the initial visit may make the older sibling feel left out or jealous. Encouraging involvement with the new baby may be more beneficial.
Choice B rationale
Spending individual time with the older sibling helps them feel valued and ensures they do not feel neglected, facilitating better acceptance of the newborn.
Choice C rationale
Having the older sibling purchase a gift for the newborn can create a positive association, but it is less impactful than ensuring individual time and attention.
Choice D rationale
Postponing the introduction until discharge can increase feelings of jealousy or resentment, as the older sibling might feel excluded from the new family dynamic during a crucial time.
Correct Answer is D
Explanation
Choice A rationale
A respiratory rate of 34/min is within the normal range for a newborn, which is typically between 30 to 60 breaths per minute. This does not indicate immediate distress.
Choice B rationale
Acrocyanosis, or bluish discoloration of the hands and feet, is common in newborns and usually resolves within the first few days of life. It is not a sign of critical illness.
Choice C rationale
Caput succedaneum, a swelling of the soft tissues of the newborn's scalp, is a common and benign condition that resolves on its own within a few days. It does not require immediate medical attention.
Choice D rationale
An axillary temperature of 36°C (96.8°F) is considered low and may indicate hypothermia in a newborn. Hypothermia can lead to serious complications, so this newborn requires immediate assessment and intervention to stabilize their body temperature.