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
Starting each feeding with the most sore breast can worsen the condition, as the infant initially sucks more vigorously at the beginning of a feeding. This might increase the pain and damage to the already sore breast.
Choice B rationale
Moisture-proof lining in breast pads can cause an accumulation of moisture, creating a breeding ground for bacteria. This can exacerbate soreness and lead to infections such as mastitis.
Choice C rationale
Breastfeeding less frequently can lead to engorgement and plugged ducts, which can further complicate breast soreness and potentially decrease milk supply. Regular feeding helps in maintaining milk flow and production.
Choice D rationale
Colostrum has natural healing properties, including immunoglobulins and growth factors, that can help heal sore and cracked nipples. Applying colostrum can promote faster recovery and reduce discomfort.
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. .