NURSING 201 Test 12 The Nursing Care of Clients During the Intrapartum

NURSING 201 Test 12 The Nursing Care of Clients During the Intrapartum NURSING 201 Test 12 The Nursing Care of Clients During the Intrapartum A 25-year-old primigravid client in the last trimester of pregnancy calls the physician's office and tells the nurse, "I think I'm in labor." 1. Which findings would warrant instructing the client to notify the physician and report to the hospital's labor and delivery unit immediately? Select all that apply. * a) The client is having contractions every 5 minutes. b) The client feels a burst of energy. * c) The client experiences a sudden gush of fluid from her vagina. d) The client experiences urinary frequency. e) The client notices blood-tinged mucous from her vagina. f) The client reports that she has felt the baby drop. R: The client is generally told that a sudden gush of fluid from the vagina indicates that the membranes have ruptured. The client should report to the hospital or designated healthcare facility because once the membranes rupture, there is an increased risk for intrauterine infection and umbilical cord prolapse if the fetal head has not engaged. The client is generally told to report to the hospital or healthcare facility when contractions are 5 minutes apart. A sudden burst of energy, also known as the "nesting instinct," is a preliminary sign of approaching labor and may occur a few days before the beginning of labor; it does not require reporting to the healthcare facility. Urinary frequency may occur as the fetus settles into the pelvic brim. The primigravid client may experience urinary frequency as early as 2 to 3 weeks before the beginning of labor. Having the baby descend into the pelvis may occur several weeks before delivery and is not a sign of labor. Blood-tinged mucous is also known as "bloody show" and may be the start of labor as the cervix dilates and effaces, but it may be several hours or a day or two before labor begins. Therefore notifying the physician and reporting to the labor and delivery unit is too early. The client arrives at the hospital and is admitted to the labor, delivery, recovery, and postpartum (LDRP) unit. The nurse obtains the client's health and pregnancy history. 2. As the nurse collects the client's history, which question has the lowest priority? a) "When did you last eat?" * b) "Have you ever had an enema?" c) "When did your contractions start?" d) "When is your baby due?" R: Upon admittance to the hospital, the least pertinent question to ask a woman who is experiencing uterine contractions is whether she has ever had an enema. Not every client requires an enema, so the best time to ask about this is shortly before administering one. It is more pertinent to ask upon admission whether the client's membranes have ruptured, when her contractions started, and when she last ate. The timing of the last meal is especially important in case the client requires anesthesia for delivery. The client informs the nurse about a previous admission to the unit 3 days ago with "false labor." 3. Which statement made by the client indicates an understanding of Braxton Hicks contractions? * a) "The contractions are less strong when I walk." b) "The contractions are regular and I can time them." c) "The contractions get stronger no matter what I am doing." d) "The contractions start in my lower back." R: Braxton Hicks contractions are irregular, painless contractions that occur intermittently (in some cases, every 10 to 20 minutes). They tend to disappear with walking and sleeping and become more uncomfortable closer to delivery. Primiparous clients often have difficulty determining the difference between false labor, as evidenced by Braxton Hicks contractions, and true labor. However, there are differences that the nurse can explain to the client. Because of their irregularity, Braxton Hicks contractions cannot be timed, and they do not increase in frequency or intensity. These contractions begin and remain in the abdomen, whereas true labor contractions begin in the lower back and progress to the abdomen. The main difference between true labor and false labor contractions, however, is that Braxton Hicks contractions do not dilate the cervix. During the admission process, the nurse obtains the client's vital signs. 4. When is the most appropriate time to take the client's vital signs? a) At the peak of a contraction, with the client positioned on the left side b) At the peak of a contraction, with the client positioned on the right side c) Between contractions, with the client positioned on the right side * d) Between contractions, with the client positioned on the left side R: To obtain the most accurate blood pressure reading, the blood pressure should be assessed between contractions, with the client in the left side-lying position. This method minimizes the possibility of obtaining an inaccurate reading that can occur when the blood pressure is measured during a contraction (when circulating blood volume decreases) or when the client is in any other position (the enlarged uterus may compress the inferior vena cava and affect blood flow). A 30-year-old primigravid client is admitted to the labor, delivery, recovery, and postpartum (LDRP) unit of a local hospital. The physician plans to perform a vaginal examination to determine the status of labor. 5. How can the nurse best prepare to assist with the vaginal examination? * a) By having sterile gloves available for the examiner b) By placing the client in the left side-lying position c) By instructing the client to halt breathing during the examination d) By giving the client an enema before the examination is performed R: When performing a vaginal examination, the examiner wears a pair of sterile gloves to avoid the introduction of bacteria and the risk of infection. The client should be assisted to the supine (not side-lying) position and assisted to use breathing techniques (breathing slowly through an open mouth) to help her relax. An enema is not usually part of client preparation for a vaginal examination. After the vaginal examination, the physician indicates that the client is in the latent phase of the first stage of labor. A progress note is written in the client's admission records. 6. When the nurse reviews the client's admission records, which assessment finding is the most reliable indicator that the client is in true labor? a) Contractions are regular and increasing in duration and intensity. b) Contractions radiate from the lower back to the lower abdomen. c) Bloody show is present. * d) The cervix is dilating. R: Dilation and effacement of the cervix are the only definite, reliable indicators of true labor. Regular, progressing contractions and the presence of bloody show are also signs of labor, but they are not considered as reliable. 7. During the latent phase, which findings can the nurse expect when assessing the client? Select all that apply. * a) Contractions occurring every 10 to 15 minutes * b) Fetal heart rate of 120 to 160 beats/minute c) Bulging perineum d) Early decelerations e) The client is irritable f) The client states, "I feel my bowels may move" R: During the latent phase the normal fetal heart rate ranges from 120 to 160 beats/minute. During the latent phase of the first stage of labor, the contractions occur every 5 to 30 minutes. The perineum does not begin to bulge until the transition phase of the first stage of labor, and early decelerations usually occur late in labor as a result of head compression. Irritability is a sign exhibited during the transition stage, and feeling the need to have a bowel movement is common as the client feels the need to push in the late stage of labor. 8. During the latent phase of labor, which instructions given by the nurse to the client are most appropriate? Select all that apply. * a) "As long as your membranes are intact, you may walk around the unit." * b) "Keep drinking clear fluids." c) "Pant when you experience a contraction." d) "Avoid bathing until after the delivery." e) "Put on your call light when you feel a contraction coming on." f) "You may have pain medication when your contractions are 2 minutes apart." R: If the client's membranes are intact and contractions are not very frequent or intense, the client may be allowed to ambulate and take a warm shower or Jacuzzi bath. During the latent phase of the first stage of labor, the client is encouraged to drink clear liquids to prevent dehydration. The client usually uses a panting breathing pattern during the transition phase of the first stage of labor. The client's contractions are monitored and therefore the nurse will know when the contraction begins and ends. In the latent phase of labor, contractions are far apart. Instructing the client that it is necessary to wait to receive pain medication until further into labor is not therapeutic. 9. During the latent phase of the first stage of labor, how often should the nurse plan to assess the fetal heart rate? a) Every 5 minutes b) Every 15 minutes * c) Every 30 minutes d) Every 60 minutes R: The fetal heart rate is assessed every 30 minutes during the latent phase of the first stage of labor, every 15 minutes during the active phase of the first stage of labor, and every 5 minutes during the second stage of labor. The client tells the nurse, "I plan to have an epidural for pain management," and asks the nurse, "When can I expect to receive it?" 10. An epidural is best performed when the client is how many centimeters dilated? a) 3 to 4 * b) 5 to 6 c) 7 to 8 d) 9 to 10 R: Epidural anesthesia can be administered at any time, but it is usually administered to a primigravid client at 5 to 6 cm dilation. If the client is multigravid, an epidural is generally given at 3 to 4 cm dilation. The registered nurse performs a vaginal examination of the client. The nurse determines that the labor is progressing and the cervix is dilated 6 cm. 11. When assessing the frequency and duration of the client's contractions during this phase of labor, the nurse expects to find that the contractions are occurring every 3 to 5 minutes and lasting up to how many seconds? a) 30 b) 40 * c) 60 d) 90 R: Contractions during the active phase of labor usually occur every 3 to 5 minutes and last between 45 and 60 seconds. Contractions last up to 30 seconds during the latent phase of the first stage of labor. They can last up to 90 seconds during the transition phase of the first stage of labor as well as during the second stage of labor. Labor has progressed, and the client enters the transition phase of the first stage of labor. 12. Which assessment finding can the nurse expect to observe during this phase? a) Cervix dilated to 10 cm b) Crowning of the presenting part * c) Increased bloody show d) Contractions lasting up to 60 seconds R: During the transition phase of the first stage of labor, the client usually has an increase in bloody show and the contractions last up to 90 seconds. Crowning of the presenting part does not occur until the cervix is completely dilated (10 cm), during the second stage of labor. 13. Which nursing action best meets the client's needs during the transition phase? a) Encouraging the client to ambulate * b) Praising the client frequently c) Instructing the client to push with each contraction d) Massaging the client's back between contractions R: During the transition phase of the first stage of labor, the client is at risk for losing control because of intense discomfort, fatigue, and frequency and length of the contractions. Praising the client's efforts frequently at this time can help her to maintain control of the situation. During the transition phase of labor, the membranes usually rupture if they have not already done so, and the client may receive an opioid analgesic or regional anesthetic; therefore, ambulation is not usually recommended. The client should not push until the cervix is completely dilated, which occurs during the second stage of labor. Application of sacral pressure can relieve back discomfort. Some women have a low tolerance to touch during this phase of labor; therefore, every client should be assessed individually to determine her preference. A 29 -year-old multiparous client who has had an uneventful, healthy pregnancy is admitted to the hospital. The physician informs the client that the active phase of the first stage of labor is in process. The records also show that the full-term baby is in the left occipito posterior (LOP) position. 14. When the fetus is in the LOP position, which nursing intervention is most appropriate? * a) Assisting the client to the knee-chest position to relieve back pain b) Placing the client in Trendelenburg position to prevent cord prolapse c) Assisting with preparation of equipment for a precipitous delivery d) Having the client void frequently to minimize displacement of the uterus R: When the fetus presents in the posterior instead of the anterior position, the client experiences back discomfort and there is a danger of maternal laceration if the fetus does not rotate before delivery. Also, the posterior position usually prolongs labor, so preparing for a precipitous delivery is not necessary. The client should be assisted to a more comfortable position. The knee-chest position is commonly recommended because it relieves discomfort associated with the posterior presentation of the head and facilitates rotation of the head. Trendelenburg position does not assist with rotation of the head to the anterior position. During this phase, the client should avoid lying on her back to avoid vena cava compression by the uterus. The uterus usually is not displaced with a posterior presentation, so having the client void is inappropriate. 15. To prevent distension of the client's bladder during the active phase of labor, which nursing intervention is most appropriate? a) Instructing the client to limit fluid intake b) Decreasing the rate of the I.V. infusion c) Offering solid foods instead of liquids * d) Encouraging the client to void every 2 hours R: The client should be encouraged to void every 2 hours to minimize bladder distension, which may prolong labor. The client should be encouraged to drink clear liquids at frequent intervals to prevent dehydration. The I.V. infusion rate is not decreased unless ordered by the physician. Maintaining the prescribed I.V. infusion rate also prevents dehydration. No solid foods are given during labor because peristalsis is slowed during this time, and nausea and vomiting can occur. 16. To correctly assess the duration of a contraction, the nurse counts the time between which intervals? * a) The beginning of one contraction and the end of the same contraction b) The end of one contraction and the beginning of the next contraction c) The beginning of one contraction and the end of the next contraction d) The beginning of one contraction and the beginning of the next contraction R: The contraction duration is defined as the time interval between the beginning of a contraction and the end of the same contraction. The time interval between the end of one contraction and the beginning of the next contraction is called the relaxation period. The time interval between the beginning of one contraction and the end of the next contraction is insignificant when assessing the client's labor pattern and is not generally measured. The time interval between the beginning of one contraction and the beginning of the next contraction is defined as the frequency of the contractions. 17. Which method is most accurate when assessing the client's contractions? * a) Place the hand over the fundus of the uterus, which is located just above the umbilicus. b) Place the hand over the inferior portion of the uterus, which is located just above the umbilicus. c) Place the hand over the fundus of the uterus, which is located midway between the umbilicus and the symphysis pubis. d) Place the hand over the inferior portion of the uterus, which is located midway between the umbilicus and the symphysis pubis. R: The nurse should palpate the fundus of the uterus, which is usually located just above the umbilicus in the full-term client. The fundus is palpated because muscular contractions are strongest and easiest to assess at this location. 18. How often should the nurse assess fetal heart rate during the active phase of labor? a) Every 5 minutes b) Every 10 minutes * c) Every 15 minutes d) Every 30 minutes R: The fetal heart rate is assessed every 15 minutes during the active phase of the first stage of labor, every 30 minutes during the latent phase of the first stage of labor, and every 5 minutes during the second stage of labor. The client tells the nurse, "I think my membranes have ruptured." The nurse performs a nitrazine test and confirms that the membranes have ruptured. 19. Which test result indicates that the membranes have ruptured? * a) The test strip turns blue. b) The test strip turns yellow. c) The test strip turns red. d) The test strip turns green. R: When there is a question about whether the membranes have ruptured, a nitrazine test may be performed. Amniotic fluid turns the nitrazine test strip blue because amniotic fluid is alkaline. The nitrazine test remains yellow when exposed to vaginal secretions and urine, which are usually acidic. Red and green are not colors associated with nitrazine testing. 20. Which actions should the nurse perform immediately after the membranes are ruptured? Select all that apply. a) Check the client's pulse. b) Insert an indwelling catheter. c) Perform a vaginal examination. * d) Check the fetal heart rate. * e) Inspect the fluid for meconium f) Prepare the room for imminent delivery R: The fetal heart rate should be checked immediately after the membranes rupture. A drop in the fetal heart rate may indicate umbilical cord prolapse. Prolapse of the umbilical cord may occur because of the sudden gush of fluid from the vagina, especially if the presenting part is not engaged. Inspecting the fluid for meconium is important because meconium-stained amniotic fluid indicates fetal distress. Rupture of the membranes can happen at any time before or during labor. Therefore, preparing for imminent delivery may be premature. The client's pulse is not affected by the rupturing of the membranes. The registered nurse usually performs vaginal examinations, and an indwelling catheter is not usually indicated when the membranes rupture. 21. After the membranes have ruptured, how often should the nurse take the client's temperature? * a) Every hour b) Every 2 hours c) Every 3 hours d) Every 4 hours R: The client's temperature should be assessed every hour after the membranes rupture because of the increased risk of infection. The temperature is assessed every 4 hours if the membranes are intact. Because the nitrazine test results indicate that the membranes have ruptured, the physician orders internal electronic fetal monitoring. The client asks the nurse," Is there any danger of this procedure causing harm to my baby?" 22. Which response by the nurse provides the best explanation of internal electronic fetal monitoring? * a) "The procedure requires attachment of a small spiral electrode to the fetal scalp and poses a slight risk of soft tissue injury and infection." b) "The procedure requires insertion of a soft, water-filled catheter into the uterus and poses no risk of injury to you or your baby." c) "The procedure requires placement of an ultrasound transducer over your abdomen and poses no risk to you or your baby." d) "The procedure requires application of a suction cup to the fetal scalp and poses a slight risk for the development of a hematoma." R: Internal electronic fetal monitoring requires the application of an electrode to the fetal scalp. Infection and soft tissue injury can occur with the use of internal electronic fetal monitoring, but both are rare. A soft, water-filled catheter is inserted into the uterus for internal electronic monitoring of uterine contractions. A transducer is applied to the mother's abdomen when external electronic monitoring is used. A suction cup is applied to the fetal scalp when a vacuum extraction is being performed to assist with delivery of the fetal head. 23. Which assessment finding is most indicative of fetal distress? a) Fetal heart rate of 140 beats/minute b) Presence of fetal heart rate accelerations * c) Presence of green amniotic fluid d) Increased amount of bloody show R: The presence of green amniotic fluid indicates that the fetus has passed a meconium stool in utero. Passage of meconium in utero when the fetus is presenting in the vertex position is an indication of fetal distress and should be reported immediately. To avoid meconium aspiration, the mouth, nose, and throat should be suctioned prior to the delivery of the baby. The normal range for the fetal heart rate is 120 to 140 beats/minute. It is normal for the fetal heart rate to accelerate. An increase in bloody show usually indicates that the second stage of labor is imminent. The client continues in active labor and tells the nurse, "I haven't had anything to eat for 24 hours. Can I have something to eat now?" 24. Which response by the nurse best explains why solid food is not given at this time? a) "It may alter the absorption of regional anesthetics." b) "It may alter the duration and frequency of contractions." c) "It may cause fetal distress." * d) "It may cause nausea and vomiting." R: Solid foods are not usually given when the client is in labor because they may cause nausea and vomiting due to the fact that peristalsis is slowed during labor. Solid foods are not known to alter the absorption of regional anesthetics or to alter the duration and frequency of contraction; they also do not cause fetal distress. After a sterile vaginal examination is performed, the client tells the nurse, "I overheard the physician say that the baby is in the vertex position. What does this mean?" 25. Which response by the nurse provides the best explanation regarding vertex positioning? * a) "The head is entering the birth canal first." b) "The feet are entering the birth canal first." c) "The buttocks are entering the birth canal first." d) "The shoulder is entering the birth canal first." R: When the fetus presents in the vertex position, the head descends into the birth canal first. If the feet or buttocks enter the birth canal first, the presentation is considered a breech. A shoulder presentation is when the shoulder enters the birth canal first. Both breech and shoulder presentations are considered malpresentations and make delivery more difficult. Often these types of presentations result in a casarean section. 26. During evaluation of the client's contractions during the active phase of the first stage of labor, when is it important for the nurse to notify the physician? a) When the contractions occur every 3 to 5 minutes b) When the contractions last longer than 45 seconds c) When the uterus relaxes between contractions * d) When the fetal heart rate drops after the acme of a contraction R: A drop in the fetal heart rate after the contraction acme is defined as a late deceleration. Late decelerations are usually a sign of fetal distress and should be reported immediately. The other options describe processes that normally occur during the active phase of the first stage of labor. The nurse is caring for a client in preterm labor. The physician writes an order for terbutaline sulfate (Brethine). 27. The nurse should carefully monitor the client for which adverse reactons to terbutaline sulfate (Brethine)? Select all that apply. * a) Anxiety * b) Tremors * c) Nervousness d) Hypoglycemia e) Oliguria f) Rash R: Drugs such as terbutaline sulfate (Brethine) are used to slow or prevent uterine contractions. They are called tocolytics and are helpful if the client is in preterm labor. Adverse reactions to terbutaline sulfate (Brethine) include anxiety, tremors, nervousness, headache, hypertension, palpitations, hypokalemia, pulmonary edema, and restlessness. Hypoglycemia, oliguria, and a rash are not common adverse reactions to terbutaline sulfate (Brethine). 28. When is it necessary for the nurse to withhold the terbutaline sulfate (Brethine) and notify the physician? a) When the electronic monitor reveals that the client is having mild contractions * b) When the cervix is dilated 4 cm or greater or effaced 50% or more c) When the electronic monitor reveals the presence of fetal heart rate variability d) When the client states that the contractions are milder and occurring less frequently R: Tocolytic agents such as terbutaline sulfate (Brethine) should be withheld if the client's cervix is dilated 4 cm or more or effaced 50% or more. Tocolytic agents should also be withheld when the client is hemorrhaging or has severe pregnancy-induced hypertension, or when fetal distress is evident. The presence of mild contractions indicates that the client continues to be in premature labor, so it would be appropriate to give the client the tocolytic medication. Fetal heart variability is a normal finding and indicates fetal well-being. The client's perception that contractions are occurring less frequently is not substantial enough to withhold the medication; more objective data are necessary. The nurse cares for a 30-year-old multiparous client who is in the transition phase of the first stage of labor. 29. Which assessment finding best indicates that the client has entered the second stage of labor? * a) The perineum is bulging. b) Contractions are lasting 30 to 60 seconds. c) The cervix is dilated to 8 cm. d) The client becomes agitated with her spouse. R: The second stage of labor begins when the cervix is fully dilated to 10 cm and ends when the baby is delivered. The perineum usually begins to bulge and the presenting part begins to crown during the second stage of labor. The contractions usually last for 60 to 90 seconds, and the cervix is completely dilated (10 cm). During transition, when the cervix is dilating from 7 to 10 cm, the client is likely to become agitated, and irritable, often times losing control. 30. When should the nurse begin delivery preparations for this client? * a) When the client is about 7 cm dilated b) When the fetal head begins to crown c) When the physician or midwife arrives d) When the client is completely dilated R: Preparation for delivery for a multiparous client should begin when she is 6 to 7 cm dilated. Preparation for a primiparous client is usually delayed until the client is completely dilated (10 cm) because it generally takes longer to achieve full dilation with a woman's first delivery. The arrival time of the physician or midwife varies and usually is not used as an indicator for when to begin preparing for delivery. The client tells the nurse, "I feel like I need to push." 31. Which action should the nurse take initially? a) Instruct the client to push when feeling the next contraction. b) Ensure that the client is in semi-Fowler's position. * c) Ensure that the client's cervix is fully dilated. d) Instruct the client to take a cleansing breath before pushing. R: A vaginal examination is performed to determine whether the cervix is 10 cm dilated and 100% effaced. The client's cervix should be completely dilated and effaced before she begins to push; this precaution prevents edema or lacerations to the cervix that would prevent further dilation, prolong labor, and possibly require delivery by cesarean birth. The other options are appropriate if the client is fully dilated. The client complains of pain and asks the nurse, "Can I have some more Stadol?" 32. The nurse correctly explains that butorphanol tartrate (Stadol) is not given at this time because opioid analgesics during this stage of labor may have which effect? a) Decrease the effectiveness of the contractions b) Cause the uterus to rupture * c) Result in respiratory depression in the newborn d) Cause increased fetal activity R: If an opioid analgesic such as butorphanol tartrate (Stadol) is given too late during labor, the medication can cross the placental barrier and may be present after the newborn is delivered, resulting in respiratory depression. Conversely, giving an opioid analgesic too early in labor may interfere with labor progression and decrease the contractions' effectiveness. Administration of an opioid analgesic is not associated with uterine rupture or increased fetal activity. The obstetrician prepares for delivery and requests that the client be prepared for epidural anesthesia. 33. The nurse is aware that, the epidural anesthetic will take how long to become effective? * a) Immediately b) In 10 to 20 minutes c) In 30 to 40 minutes d) In approximately 1 hour R: Epidural blocks provide pain relief during labor and delivery by blocking the pain sensations transmitted to the brain. Blocks are also useful for clients who have preexisting conditions, such as heart disease, pulmonary disease, or diabetes. An epidural usually takes effect immediately and reaches its maximum potency within 3 to 5 minutes of administration. 34. The nurse assesses for which complication during the immediate post procedural period? * a) Maternal hypotension b) Fetal tachycardia c) Spinal headache d) Lower extremity paralysis R: During the immediate postprocedural period, the client's blood pressure should be assessed and evaluated for the presence of hypotension; a drop in blood pressure occasionally occurs secondary to sympathetic blockade and may decrease the oxygen supply to the fetus, which is manifested by fetal bradycardia (not tachycardia). Paralysis of the lower extremities is an expected result of a saddle block. The client may experience a spinal headache within 24 to 72 hours of the procedure, but not immediately. Ensuring that the client is well hydrated (usually through I.V. infusion) before, during, and after the procedure minimizes both maternal hypotension and spinal headache. 35. Which modification to the client's care plan is required after the client has undergone the epidural? a) Oxygen is administered. * b) The nurse instructs the client when to push. c) Oxytocin (Pitocin) is administered to augment labor. d) The client is catheterized. R: The client who has had an epidural anesthesia is instructed when to push because she is unable to feel contractions. Oxygen is not routinely required unless complications arise. The client is not usually catheterized following this type of anesthesia, and the epidural is usually given late in labor (second stage) or for cesarean birth; therefore, it usually does not slow the progress of labor, which would require the use of oxytocin (Pitocin). 36. Which sequence should the nurse follow when cleaning the client's perineum in preparation for delivery of the baby? * a) Pubic bone to lower abdomen, both inner thighs, right and left labia, vagina to anus b) Vagina to anus, right and left labia, both inner thighs, pubic bone to lower abdomen c) Both inner thighs, right and left labia, vagina to anus, pubic bone to lower abdomen d) Left and right labia, vagina to anus, both inner thighs, pubic bone to lower abdomen R: When cleaning the perineum in preparation for delivery, the nurse should use the technique that poses the least possibility of infection and increases visibility of the area. The usual procedure of cleaning the area is as follows: pubic bone to lower abdomen, the inner thighs (both), the right and left labia, and the vagina to the anus. The vagina is always the last area cleaned. The physician informs the client that she needs to have an episiotomy. The client begins to cry and asks the nurse, "Why do I have to have an episiotomy?" 37. Which response by the nurse best explains the need for an episiotomy? a) "An episiotomy is necessary to prevent uterine rupture." b) "An episiotomy is necessary to prevent postpartum infection." * c) "An episiotomy is necessary to prevent perineal laceration." d) "An episiotomy is necessary to prevent rectal trauma." R: An episiotomy is an incision made into the perineum tissue to enlarge the vaginal opening. It is usually performed to prevent lacerations of or damage to the perineum. An episiotomy also diminishes the possibility of prolonged pressure on the fetal head and speeds the delivery process. Episiotomies are not associated with uterine rupture, postpartum infection, or rectal trauma. A 31-year-old client just delivered a healthy baby girl. The nurse tells the father that the infant will receive an injection of vitamin K (AquaMEPHYTON) and erythromycin (Ilotycin) eye ointment. 38. To meet the infant's priority needs immediately after delivery, which of the following equipment should the nurse have ready? a) Cord clamp b) Warm blanket * c) Bulb syringe d) Oxygen supply R: The priority need of the newborn immediately after delivery is establishment of a patent airway. This is best accomplished by bulb-suctioning the newborn's nose and mouth after the head is delivered but before complete delivery of the body. Oxygen is not given before the airway is cleared; it is only administered if needed. Applying the cord clamp and warming the newborn do not take priority over establishment and maintenance of respirations. The newborn is assigned an Apgar score of 7 at 5 minutes. 39. On the basis of the baby's Apgar score, the nurse anticipates providing care for a newborn in what condition? a) Severely distressed b) Moderately distressed c) Stable but requiring close monitoring * d) Vigorous with no signs of distress R: The Apgar scoring system is a tool used to assess the infant at 1 minute of age and at 5 minutes. It assesses heart rate, respiratory effort, muscle tone, reflexes, and color. The maximum score an infant can achieve is 10 (2 points for each of the five categories). An Apgar score of 7 to 10 is considered good and does not require any intervention. A score between 4 and 6 indicates moderate distress, in which case the newborn requires close monitoring and possible intervention with oxygen. A score between 0 and 3 is considered poor and indicates a definite need for resuscitation efforts and medical intervention. 40. To best facilitate mother-infant attachment and prevent the newborn from developing distress, what should the nurse do initially? a) Give the newborn to the mother immediately after initial care is given in the delivery room. * b) Immediately dry the newborn, then place the infant skin-to-skin on the mother's abdomen. c) Place the newborn in a radiant warmer for 5 minutes, then wrap the newborn and give the infant to the mother. d) Place the newborn in the radiant warmer, and position the warmer so the mother can see the infant. R: The newborn is dried first to prevent heat loss secondary to evaporation, placed on the mother's abdomen in skin-to-skin contact, and then covered with a warmed blanket. The mother's abdomen is usually warm, so direct newborn-mother contact does not pose a danger of heat loss. The other options either interfere with maintaining the newborn's warmth or do not promote mother-infant attachment. 41. When preparing to administer vitamin K (AquaMEPHYTON) to the infant, the nurse chooses which site for injection? Place an X on the appropriate site. Ans: R: The preferred site for I.M. injections in a newborn is the vastus lateralis, located on the outside aspect of the thigh. The rectus femoris may also be used. The ventrogluteal muscle and the gluteus maximus muscles are not used in newborns because of the risk of sciatic nerve damage. The deltoid muscle should not be used until a child is 3 years old. 42. When the infant's father asks what the purpose of Vitamin K is, the nurse correctly explains that vitamin K (AquaMEPHYTON) is given for what reason? a) To stimulate respirations b) To start peristaltic movements * c) To decrease the risk for hemorrhage d) To increase calcium absorption R: Bacteria normally found in the intestines synthesize vitamin K. The newborn is given vitamin K (AquaMEPHYTON) at birth because his intestines are sterile and he cannot synthesize his own vitamin K. Vitamin K is needed for formation of prothrombin and other clotting factors that help prevent bleeding. Vitamin K does not stimulate respirations, start peristalsis, or increase calcium absorption. The infant's father also wants to know about the ointment that is being placed in the baby's eyes. 43. The nurse explains to the father that erythromycin (Ilotycin) is given to protect the infant from neonatal blindness, which can occur if the infant develops an eye infection caused by which organisms? * a) Gonococcal and chlamydial organisms b) Gonococcal and streptococcal organisms c) Gonococcal organisms and Candida albicans d) Gonococcal organisms and Pneumocystis carinii R: Neonatal blindness can occur as a result of eye infections caused by gonococcal and chlamydial organisms. Erythromycin (Ilotycin) ophthalmic ointment is used prophylactically in the newborn to prevent blindness that may result from exposure to these organisms during passage through the mother's birth canal. Candida albicans causes yeast infections and Pneumocystis carinii is associated with acquired immunodeficiency syndrome. 44. After instillation of the eye ointment, the nurse informs the father that the baby may experience which of the following? a) Swelling of the eyes * b) Temporary blurred vision c) Purulent eye drainage d) Conjunctival hemorrhage R: The infant may experience temporary blurred vision following administration of erythromycin (Ilotycin) ophthalmic ointment. The infant's eyes may swell, but this is more likely the result of pressure exerted on the soft tissue of the lids during passage through the birth canal. Purulent eye drainage and conjunctival hemorrhage are not associated with the use of this drug. The patient care technician weighs the newborn. 45. Which action by the technician indicates a need for additional teaching regarding accurate and safe assessment of the newborn's weight? a) The technician undresses the newborn before obtaining the weight. b) The technician places a diaper or paper barrier on the scale before balancing it. * c) The technician keeps one hand on the newborn while obtaining the weight. d) The technician cleans the scale with an antiseptic before using it. R: The technician or nurse should keep one hand over the newborn while weighing it. Keeping a hand on the newborn will affect the weight's accuracy. Undressing the newborn before the weight is obtained, placing a diaper or paper barrier on the scale before balancing it, and cleaning the scale with an antiseptic before and after use are all correct techniques to implement when weighing a newborn. 46. Which intervention is most important for the nurse to implement before transporting the newborn from the delivery area to the nursery? * a) Placing matching identification bracelets on mother and baby b) Administering prophylactic eye medication c) Giving I.M. vitamin K (AquaMEPHYTON) d) Obtaining a blood sample for phenylketonuria (PKU) testing R: To prevent the risk of the mother receiving the wrong baby, matching identification bracelets should be placed on both the newborn and mother before the newborn's leaving the delivery area. Eye prophylaxis and administration of vitamin K (AquaMEPHYTON) are usually delayed to facilitate early bonding between the mother and baby but are completed in the delivery room or in the nursery. Phenylketonuria (PKU) testing should be performed when the baby has begun to eat. The nurse observes the client for signs of impending delivery of the placenta. 47. To facilitate delivery of the placenta, what should the nurse instruct the client to do? a) Turn on the right or left side. b) Breathe slowly and deeply. c) Tighten and relax the perineum intermittently. * d) Push when feeling a contraction occurring. R: The placenta is delivered after it has separated from the wall of the uterus. This is usually accomplished by having the client bear down. In some cases, the attending healthcare provider may manually express the placenta. Breathing slowly and deeply, assuming a side-lying position, and tightening and relaxing the perineum do not facilitate delivery of the placenta. 48. Which observation regarding the delivery of the placenta should the nurse report to the physician? a) Bulging perineum b) Shortening of the umbilical cord * c) Rise of the fundus in the abdomen d) Decreased vaginal discharge R: A rise of the fundus in the abdomen, lengthening of the umbilical cord, and a sudden gush of blood from the vagina are signs of impending delivery of the placenta. The perineum does not bulge with delivery of the placenta. Just after the delivery of the placenta, the client complains of uncontrollable shaking and of being cold. 49. Which actions by the nurse are most appropriate at this time? Select all that apply. * a) Explain that the shaking is normal. * b) Place a warmed blanket over the client. c) Suggest the client try to ignore the shaking. d) Notify the physician or nurse-midwife. e) Take the client's temperature. f) Provide a warm beverage. R: The client's needs are best met by applying a warmed blanket over her. The nurse can also explain that the shaking is a normal response due to sudden physiological changes and fluid shifts; however, this will not relieve her shaking and coldness. Suggesting that the client try not to think about the shaking will not resolve the underlying cause; therefore, this does not adequately address the client's complaint. Notifying the physician is unnecessary because this is a normal physiological process. Because the shaking and feelings of being cold are related to fluid shifts and sudden physiological changes, taking the client's temperature is not necessary. Providing a warm drink may provide warmth, but will not control the shaking. Therefore, it is not an immediate action. 50. At which location can the nurse expect to palpate the fundus of the uterus immediately after delivery? * a) At or just below the level of the umbilicus b) Just above the level of the umbilicus c) Just above the level of the symphysis pubis d) Midway between the umbilicus and symphysis pubis R: Following delivery of the placenta, the fundus of the uterus should be firmly contracted and located at, or just below, the level of the umbilicus. 51. When performing postpartal checks just after delivery, which assessment findings should the nurse report immediately? Select all that apply. * a) A pulse rate between 120 and 130 beats/minute b) Presence of dark red, fleshy-smelling lochia c) Saturation of one perineal pad per hour * d) A systolic blood pressure less than 90 mm Hg e) A respiratory rate of 24 breaths/ minute * f) Cool, clammy skin R: A systolic blood pressure of 100 mm Hg or less should be reported because it could indicate that the client is hemorrhaging. Signs of hypovolemic shock occur when about 400 to 500 mL of blood have been lost. Besides a drop in blood pressure, other signs of shock related to hemorrhage include increased pulse rate, increased respiratory rate, cold and clammy skin, decreased urine output, and dizziness. The normal pulse rate is slightly lower during the fourth stage of labor than during previous stages because of decreased cardiac strain. The pulse rate can range between 40 and 80 beats/minute and still be considered normal. During the fourth stage of labor, the lochia is usually dark red with a fleshy, not foul, odor. The client may saturate one perineal pad within 1 hour. The placenta is delivered and the physician sutures the episiotomy. The physician instructs the nurse to add oxytocin (Pitocin) to the client's I.V. fluids. The client asks the nurse, "Why do I need this drug?" 52. The nurse explains that oxytocin (Pitocin) is given after delivery of the baby and placenta for which purpose? a) To increase the blood pressure b) To prevent the uterus from inverting * c) To decrease the likelihood of hemorrhage d) To prevent rupture of the uterus R: Oxytocin (Pitocin) decreases the risk of hemorrhage after delivery because the medication causes uterine contractions. The client's blood pressure should be monitored closely because hypertension is a side effect of this medication. Also, uterine rapture may occur with the administration of oxytocin (Pitocin) if hyperstimulation of the uterus secondary to a toxic dose of the medication occurs. Administering oxytocin (Pitocin) will not prevent the uterus from inverting. When palpating the uterus, the nurse commonly supports it just above the symphysis pubis to prevent the uterus from inverting. A 26-year-old gravida I client is admitted to the hospital in active labor. During the physician's examination, it is determined that the client has cephalopelvic disproportion. A cesarean birth using epidural anesthesia is scheduled. The physician orders the insertion of an indwelling urinary catheter before surgery. The client asks the nurse, "Why do I need a urinary catheter?" 53. Which response by the nurse regarding the placement of the indwelling catheter is most accurate? a) "It prevents the development of postpartum hemorrhaging." * b) "It keeps the bladder empty during the surgical procedure." c) "It's used as a landmark for the physician during surgery." d) "It's inserted to provide a safe way of collecting urine specimens." R: The client is catheterized before abdominal surgery to prevent bladder trauma that may occur if the bladder becomes distended during surgery. Such catheterization is not performed to reduce postpartum hemorrhage, provide a landmark for the physician, or provide a safe way of collecting urine specimens. The client asks the nurse if she will feel any pain while the surgery is performed. 54. Which response by the nurse regarding the client's pain is most appropriate? * a) "You may experience pressure, but you will not feel any pain during the procedure." b) "You may experience a brief sting when the first incision is made." c) "You won't remember anything about the procedure because you will be asleep." d) "You won't feel any pain once the anesthesia takes effect." R: When a cesarean birth is performed using epidural anesthesia, the client may feel pressure but does not experience pain or stinging because the nerve roots (source of pain) are blocked. Clients are not asleep when this type of anesthesia is used. The client's husband asks the nurse if he can remain with his wife during the cesarean birth. 55. Which statement by the nurse is most appropriate in response to the husband's request? a) "Only your wife and surgical personnel are allowed in the operating room to maintain a sterile environment." b) "You can join your wife in the operating room only after the baby has been delivered and your wife and baby are stable." * c) "You can join your wife in the operating room after you change into the appropriate attire." d) "You can join your wife at the time of transfer to the recovery area and the effects of the anesthesia have worn off." R: The client's husband (or partner or coach) is usually allowed in the operating room during the cesarean birth. However, because of the sterile environment, whoever is observing the birth must first scrub and change into the appropriate attire before being brought into the surgical area when the procedure is ready to begin. Then the person is usually seated near the client's head. The client is transferred to the operating room. The physician plans to perform a lower-segment transverse incision and requests that the nurse perform the surgical skin preparation. 56. Which method of cleansing the abdomen is most appropriate? * a) The nurse cleanses the entire abdomen beginning at the level of the nipple line. b) The nurse cleanses the entire abdomen beginning at the top of the uterine fundus. c) The nurse cleanses the entire abdomen beginning at the level of the umbilicus. d) The nurse cleanses the entire abdomen beginning 6" (15 cm) above the mons pubis. R: Before a cesarean birth, the nurse performs an abdominal-perineal preparation. The area prepared begins at the nipple line and extends vertically to the perineal area visible when the legs are parallel and then horizontally from one side of the abdomen to the other side of the abdomen. The cesarean birth is performed without complications. About I % hours after surgery, the client is transferred in stable condition to the postpartum unit. The abdominal dressing is dry and intact, the indwelling catheter is patent and draining clear yellow urine, and I. V. fluids are infusing at the prescribed rate. The client also has a continuous infusion of epidural morphine sulfate. 57. While the client is receiving epidural morphine sulfate, the nurse closely monitors the client for which adverse reaction? a) Urinary incontinence b) Pupil dilation * c) Respiratory depression d) Elevated blood pressure R: The client should be monitored for respiratory depression when receiving morphine by the epidural route. Respiratory depression is the most serious adverse reaction associated with administration of opioids by this route. The client may also experience urine retention, pinpoint pupils, and circulatory collapse. 58. Which medication should the nurse plan to have readily available while the client is receiving epidural morphine sulfate? a) Buprenorphine hydrochloride (Buprenex) b) Calcium gluconate (Calsan) c) Atropine sulfate (Atropair) * d) Naloxone hydrochloride (Narcan) R: An opioid antagonist such as naloxone hydrochloride (Narcan) should be readily available in case respiratory depression occurs. If Narcan is used, the nurse should monitor the client for extreme pain. The medications identified in the other options are not required when the client is receiving epidural morphine sulfate. Twenty-four hours after surgery, the physician writes orders to discontinue the morphine epidural, I. V. therapy, and indwelling catheter and to administer propoxyphene and acetaminophen (Darvocet N 50) 2 tabs P. O. every 3 to 4 hours p.r.n. for pain. The physician also removes the abdominal dressing and says the client may shower and ambulate as tolerated. 59. Which assessment finding best indicates the presence of infection of the abdominal incision line? a) The client states that the incision line feels numb. b) The client's oral temperature is 99°F (37.2°C). c) The incision line is approximated. * d) The incision line is red and swollen. R: Redness and swelling around the incision usually indicate the presence of an infection. Other signs of infection include an elevated temperature (100.4°F [38°C] or greater orally) 2 to 3 days after delivery, severe pain, and incisional drainage. It is normal for the incision line to feel numb for several months following a cesarean birth. The day after surgery, the client complains of abdominal pain and bloating. The nurse notes that the client's abdomen is distended. 60. Which intervention is most appropriate to relieve the client's discomfort? * a) Assist the client to ambulate in the hall. b) Insert a rectal tube to monitor bowel function. c) Administer the prescribed pain medication. d) Instruct the client to use a straw when drinking fluids. R: Ambulation, a diet low in gas-forming foods, small enemas, and antiflatulence medications are some methods used to reduce abdominal discomfort that may be experienced by the client who has had a cesarean birth. Pain medications, such as meperidine hydrochloride (Demerol) and morphine sulfate, can contribute to the abdominal discomfort instead of relieving it because they slow peristalsis. Rectal tubes are not usually used postpartally. Drinking from a straw is discouraged because it causes the client to swallow more air, which further aggravates the problem. The client tells the nurse, "I'm disappointed that it was necessary to have a delivery by cesarean section," then asks the nurse, "If I have another baby, will I have to have another cesarean?" 61. Which response by the nurse is most accurate regarding a vaginal birth after a cesarean birth (VBAC)? * a) "It may be possible to have a VBAC if the previous cesarean incision was a classical incision." b) "A vaginal birth is not recommended after a cesarean birth because of the danger of uterine rupture." c) "A vaginal birth is just as painful as a cesarean birth because an episiotomy has to be performed." d) "A VBAC may be possible if there is no history of medical conditions that prohibit it." R: Vaginal birth after a cesarean birth (VBAC) is possible if the client has had a classical (low transverse) incision and wishes to attempt to have a vaginal birth. The client must also have no history of medical conditions that prohibit a vaginal birth. A 25-year-old primigravid client is in the active phase of the first stage of labor when her membranes rupture. The nurse notes a decrease in the fetal heart tones on the electronic monitor. Upon inspection of the perineum, the nurse observes that the umbilical cord is protruding through the vagina. 62. Which action is most appropriate for the nurse to take initially? a) Turn the client on the left side. b) Notify the physician of the findings. * c) Place the client in Trendelenburg position. d) Prepare a sterile field for delivery of the baby. R: If the nurse observes prolapse of the umbilical cord, the client should be placed in the Trendelenburg or knee-chest position. Both positions help to relieve the pressure of the presenting part on the umbilical cord. The nurse may also attempt to lift the presenting part off the cord with a gloved finger or hand until the physician or midwife arrives. Oxygen is usually administered, but the client is not positioned on the left side. The newborn is usually delivered by cesarean birth; however, preparation of the delivery area and notification of the physician do not take priority over relieving the cord compression. A 32 -year-old client with a history of precipitous labor is admitted to the hospital. She states that contractions are occurring every 2 to 3 minutes. When observing the client’s perineum, the nurse notes that the baby's head is crowning. The nurse is alone with the client and unable to obtain assistance. 63. At this point, what is most appropriate for the nurse to do after putting on sterile gloves? * a) Gently place one hand on the crowning head, and allow the head to emerge slowly between contractions. b) Push back firmly on the head, and place pressure on the vaginal meatus until the physician arrives. c) Place a sterile towel over the perineal area, and have the client bring the legs close together. d) Slide a finger into the vagina, and enlarge its exit while delivering the head during a contraction. R: When birth is imminent and no help is available, the nurse should gently control the delivery of the head, allow it to emerge, and deliver the newborn between contractions. The nurse should not hold back the baby's head to prevent birth or attempt to enter or enlarge the vaginal opening. A 26 -year-old primigravid client at 40 weeks' gestation is admitted to the hospital after contacting the physician about not having felt the baby move for 24 hours. The nurse is unable to detect a fetal heartbeat using the external fetal monitor. The physician examines the client and determines that the fetus is dead. An infusion of oxytocin (Pitocin) is ordered for induction of labor. The client is crying and tells the nurse, "This can't be true. You must have made a mistake." 64. Which nursing intervention is most appropriate at this time? a) Recheck the fetal heart tones with the electronic external fetal monitor so that the client can listen. * b) Express sorrow about the client's loss and encourage the client to express feelings. c) Redirect the client's attention to the laboring process and the correct use of breathing techniques. d) Explain that the baby probably would have been born with severe long-term health problems. R: The nurse should encourage the client to express her feelings, including sorrow over her baby's loss. These actions allow the client to sort through her feelings and facilitate the establishment of a trusting relationship between the client and nurse. The fetal heart rate should be checked only once by an experienced nurse; any rechecking may give the client false hope, which is inappropriate. Redirecting the client's attention to the laboring process does not allow the client the opportunity to sort through her feelings. Explaining that the baby probably would have been born with severe long-term health problems is not necessarily an accurate statement and also does nothing to ease the client's sorrow. The baby is delivered stillborn. Following stabilization, the client is transferred to a private room on a wing adjacent to the labor, delivery, recovery, and postpartum (LDRP) unit. The client's husband is present. The client asks the nurse about seeing the baby. 65. Which action is most appropriate for the nurse to take at this time? a) Substitute a memory packet, including such items as a picture of the baby and footprints. * b) Bring the infant and allow the couple to view the baby privately. c) Encourage the client to postpone viewing the baby until after having had an opportunity to receive counseling. d) Bring the infant, but do not allow the parents to hold or touch the infant. 66. Which finding would the nurse consider abnormal for the postpartum client who delivered within the last 24 hours? a) The client has passed a couple of nickel-sized clots. * b) The client has calf pain when a foot is dorsiflexed. c) The client has abdominal cramping while breast-feeding. d) The client's vaginal discharge is dark red. R: Calf pain when the foot is dorsiflexed is a manifestation of thrombophlebitis. This response is also called a "positive Homans' sign." Thrombophlebitis, the inflammation of the lining of a blood vessel with clot formation, can involve superficial or deep veins. Clients at risk for developing thrombophlebitis include obese women, those with varicose veins, multiparas, and those older than age 30. It is normal for the client to pass a couple of nickel-sized clots during the first 24 hours after delivery. The client may experience abdominal cramping similar to contraction pain during labor; these contractions are caused by the release of oxytocin when the client is breast-feeding and are more common in multiparous clients. The vaginal discharge is normally dark red during this time. 67. Which of the following clients is at highest risk for developing postpartum hemorrhage? Select all that apply. * a) A client with placenta previa * b) A client who just delivered triplets * c) A client who delivered her sixth baby d) A client whose fetus had late decelerations e) A client with a history of primary hypertension * f) A client who had a precipitious delivery R: Postpartal hemorrhage is a serious, life-threatening condition that can occur within the first 24 hours and up to the first 6 weeks postpartum. The nurse must observe the client closely during the first 24 hours and recognize those clients who are at greatest risk for hemorrhaging. These clients include those who have a placenta previa or and abruptio placenta, clients who have just delivered multiple infants, clients with high parity, and those who have had a precipitious (rapid) delivery. Other clients who are at risk for postpartal hemorrhage include those who have had a difficult or prolonged delivery, hydramnios, induction of labor using Pitocin, and a forceps delivery. Late decelerations of the fetus are not a risk factor for maternal postpartal hemorrhage, nor is primary hypertension. 68. To prevent hemorrhage, when should the nurse massage the fundus during the postpartal period? a) When the fundus is firm and hard b) When the fundus is at the umbilicus c) When the amount of lochia decreases * d) When the fundus is soft and boggy R: A soft and boggy fundus can lead to uterine bleeding. Normally, the fundus is firm, hard, and located at, or just below, the level of the umbilicus. The uterus should be massaged if there is any increase in the lochia flow. 69. The nurse correctly massages the fundus by placing one hand on the fundus and the other hand where? * a) Just above the symphysis pubis b) To the right side of the abdomen c) Just below the xiphoid process d) To the left side of the abdomen R: Placing one hand on the fundus of the uterus and the other hand just above the symphysis pubis prevents the uterus from becoming inverted. The hand placement in the other options will not prevent the uterus from inverting. A 33-year-old client delivered a healthy infant vaginally 6 hours ago. During the delivery, the physician performed a mediolateral episiotomy. Although in stable condition, the client experiences incisional discomfort. 70. How should the nurse position the client when assessing the perineum after an episiotomy? a) Prone b) Supine * c) Sims' position d) Lithotomy position R: An episiotomy is the surgical incision made by the physician to avoid perineal tears during delivery. When assessing the perineum of the client who received an episiotomy, the nurse should assist the client to the left side-lying position with the right leg flexed at the knee (Sims' position). The upper buttock is lifted to expose the anus and perineum. This technique allows the best visualization of the perineal area. The positions identified in the other options do not allow for maximal visualization of this area. 71. Which nursing intervention is most appropriate for relieving discomfort associated with episiotomy repair? a) Sitz bath * b) Ice pack c) Heat lamp d) Topical cortisone R: An episiotomy is a surgical cut into the perineum to widen the vaginal opening. If the client has an episiotomy, ice is applied to the perineum to reduce the swelling and subsequently decrease the discomfort that may occur from swelling. Sitz baths, heat lamp treatments, and topical cortisone are usually ordered for use after the fourth stage of labor. 72. Which assessment finding by the nurse best indicates the presence of a perineal hematoma? a) The client complains of a feeling of fullness in the vagina. b) Lochia rubra is heavy and foul-smelling. c) There is separation and purulent drainage from the episiotomy. * d) The client complains of severe pain in the perineal area. R: A hematoma is the collection of blood in tissue that occurs when a vessel ruptures. A client who develops a perineal hematoma usually complains of a great deal of pain in the perineal area, especially when sutures were needed to repair the episiotomy. The condition should be reported promptly. A hematoma is not associated with a feeling of fullness in the vagina, the presence of heavy and foul-smelling lochia rubra, or separation and purulent drainage from an episiotomy. During the initial assessment, the nurse notes that the client's fundus is one fingerbreadth above the umbilicus and displaced to the right of the abdominal midline. 73. Which action is most appropriate for the nurse to take in response to this find