The laboratory results for a postpartum woman are as follows:

blood type: A +

rubella: non-immune

hematocrit: 30%

GBS: negative
How would the nurse best interpret these data?

A) Pauses in respiration lasting 30 seconds:
Pauses lasting longer than 20 seconds or accompanied by other signs of distress would warrant further evaluation. A 30-second pause by itself, without additional concerning symptoms, is generally not a reason for immediate action.

B) Respiratory rate 36, crackles present bilaterally:
The presence of bilateral crackles is concerning. Crackles can indicate fluid in the lungs, possibly from retained amniotic fluid or respiratory distress syndrome (RDS). In a term newborn, bilateral crackles at this time, especially if accompanied by tachypnea or other signs of respiratory distress, may indicate a serious respiratory issue, such as aspiration pneumonia or RDS. Immediate assessment and intervention are necessary to ensure the infant is breathing adequately and that there are no underlying complications.

C) Apical heart rate of 160 with mild systolic murmur heard:
An apical heart rate of 160 is within the normal range for a newborn (typically 120-160 bpm). A mild systolic murmur is also not uncommon in newborns and may be benign, especially in the first few days of life. Murmurs are often transient and can be caused by normal circulatory changes as the newborn's cardiovascular system adjusts after birth. Although a heart murmur should be monitored, it is not typically an urgent concern unless associated with signs of poor perfusion or other cardiac symptoms.

D) Small white papules on nose and chin:
These small white papules are likely milia, which are common and harmless in newborns. Milia are keratin-filled cysts that typically appear on the face, especially around the nose and chin. They are a normal finding and resolve on their own without treatment. These papules do not require immediate action.

A) Fundus below the symphysis and not palpable:
The process of involution refers to the shrinking and returning of the uterus to its normal size and position after delivery. By postpartum day 14, the uterus should be largely involuted, with the fundus no longer palpable above the pubic symphysis. This is a normal finding, as the uterus typically shrinks to its pre-pregnancy size over this period. The fundus should be at or below the symphysis pubis and should not be palpable after about two weeks postpartum, indicating that the involution process is proceeding as expected.

B) Moderate, bright red lochia:
While bright red lochia (also known as lochia rubra) is common during the first few days postpartum, by postpartum day 14, lochia should have transitioned to a serosa (pinkish or brownish) or alba (white or yellowish) appearance. Bright red lochia on day 14 would suggest a possible issue, such as retained placental fragments or uterine atony, and would require further evaluation.

C) Breasts warm, firm and tender:
Breast tenderness and firmness can be normal in the early postpartum period, especially as milk comes in. However, by postpartum day 14, if the breasts remain tender and warm, this could indicate mastitis or engorgement that hasn't been resolved. While some tenderness may still occur, it should have decreased by this point. If tenderness persists, further assessment would be needed.

D) Laceration slightly red and puffy:
Postpartum lacerations or episiotomy sites should begin to heal within the first few days, but slight redness and swelling might still be present at two weeks. However, puffiness or continued redness after 14 days may indicate poor healing, infection, or other complications, which requires further evaluation and intervention. Normal healing should show a decrease in redness and swelling by this time.