Introduction

Introduction ( 6 Questions)

A nurse is assessing a client who had a prolonged labor and vacuum-assisted birth.

The nurse observes a large, tense, bluish bulge on the client’s perineum.

The client reports severe pain in the area.

What is the most likely diagnosis for this client?



Correct Answer: A

Perineal hematoma. A perineal hematoma is a collection of blood in the soft tissues of the perineum that can result from trauma during delivery, such as vacuum-assisted birth. The client may present with a large, tense, bluish bulge on the perineum and severe pain in the area.

Choice B. Vulvar varicosity is wrong because it is a condition where the veins in the vulva become enlarged and swollen due to increased blood flow and pressure during pregnancy. It usually appears as bluish or purple veins on the vulva and may cause discomfort, itching, or heaviness in the area.

It is not related to vacuum-assisted birth or prolonged labor.

Choice C. Rectocele is wrong because it is a condition where the rectum bulges into the vagina due to weakening of the pelvic floor muscles and connective tissue.

It may cause symptoms such as difficulty with bowel movements, a feeling of pressure or fullness in the vagina, or sexual dysfunction.

It is not related to vacuum-assisted birth or prolonged labor.

Choice D. Episiotomy is wrong because it is a surgical incision made in the perineum to enlarge the vaginal opening during delivery.

It may be done to facilitate delivery, prevent severe tearing, or protect the baby’s head from trauma.

It is not a diagnosis but a procedure that may be performed during vacuum-assisted birth or normal vaginal delivery.




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