What documentation on a woman's chart on postpartum day 14 indicates a normal involution process?
Breasts firm and tender
Episiotomy slightly red and puffy
Fundus below the symphysis and not palpable
Moderate bright red lochial flow
The Correct Answer is C
Choice a) Breasts firm and tender is incorrect because this is not a sign of normal involution, but rather a sign of breast engorgement, which is a common problem in the first few weeks of breastfeeding. Breast engorgement occurs when thE breasts become overfilled with milk, causing them to feel hard, swollen, painful, and warm. It can be prevented or relieved by frequent and effective breastfeeding, applying warm or cold compresses, massaging the breasts, expressing some milk, and wearing a supportive bra.
Choice b) Episiotomy slightly red and puffy is incorrect because this is not a sign of normal involution, but rather a sign of inflammation or infection of the perineal wound. An episiotomy is a surgical cut made in the perineum (the area between the vagina and the anus) to enlarge the vaginal opening during delivery. It can take several weeks to heal and may cause pain, swelling, bruising, bleeding, or discharge. It can be cared for by keeping the area clean and dry, applying ice packs or witch hazel pads, taking painkillers or sitz baths, and avoiding constipation or straining.
Choice c) Fundus below the symphysis and not palpable is correct because this is a sign of normal involution, which is the process of the uterus returning to its pre-pregnancy size and shape after delivery. The fundus is the upper part of the uterus that can be felt through the abdomen. Immediately after delivery, the fundus is about the size of a grapefruit and can be felt at or above the umbilicus (the navel). It gradually descends about one fingerbreadth per day until it reaches the level of the symphysis pubis (the joint where the two pubic bones meet) by about 10 days postpartum. By 14 days postpartum, the fundus should be below the symphysis and not palpable.
Choice d) Moderate bright red lochial flow is incorrect because this is not a sign of normal involution, but rather a sign of excessive or prolonged bleeding after delivery. Lochia is the vaginal discharge that consists of blood, mucus, and tissue from the lining of the uterus. It changes in color and amount over time, from red to pink to brown to yellow to white. The normal lochia flow should be scant to moderate in amount, dark red to brown in color, and last for about 4 to 6 weeks postpartum. A moderate bright red lochial flow on day 14 postpartum may indicate that the uterus is not contracting well or that there is an infection or retained placental tissue in the uterus.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A: This is incorrect because Standard Precautions are a set of guidelines that apply to all patients, regardless of their infection status. They include using personal protective equipment, handling sharps and waste properly, and cleaning and disinfecting equipment and surfaces. However, they are not enough to prevent neonatal infection, as some pathogens can still be transmitted by contact or droplet.
Choice B: This is the correct answer because good hand hygiene is the most effective way to prevent the transmission of microorganisms that can cause neonatal infection. The nurse should wash their hands with soap and water or use an alcohol-based hand rub before and after touching the infant, the infant's environment, or any items that come in contact with the infant. The nurse should also educate the parents and visitors on the importance of hand hygiene and how to perform it correctly.
Choice C: This is incorrect because a separate gown technique involves wearing a clean gown for each infant and discarding it after use. This can help prevent cross-contamination between infants, but it does not eliminate the need for hand hygiene. The nurse should still wash their hands before and after wearing a gown, as well as before and after touching the infant or any items that come in contact with the infant.
Choice D: This is incorrect because isolation of infected infants involves placing them in a separate room or area with restricted access and using additional precautions based on the mode of transmission of the infection. This can help prevent the spread of infection to other infants, staff, or visitors, but it does not eliminate the need for hand hygiene. The nurse should still wash their hands before and after entering and leaving the isolation area, as well as before and after touching the infant or any items that come in contact with the infant.
Correct Answer is B
Explanation
Choice A: This is incorrect because acetylsalicylic acid (ASA), also known as aspirin, is not a cure for preeclampsia, but a preventive measure. ASA may reduce the risk of preeclampsia in some high-risk women by inhibiting platelet aggregation and improving blood flow to the placenta. However, ASA is not recommended for all pregnant women, as it may have adverse effects on the mother and the fetus, such as bleeding, premature closure of the ductus arteriosus, or fetal growth restriction.
Choice B: This is the correct answer because delivery of the fetus is the only definitive treatment for preeclampsia, as it eliminates the source of the placental factors that cause the condition. Preeclampsia is a multisystem disorder characterized by hypertension, proteinuria, and edema that occurs after 20 weeks of gestation. It is caused by abnormal placentation and endothelial dysfunction that lead to vasoconstriction, inflammation, and coagulation.
Delivery of the fetus and the placenta resolves these abnormalities and restores normal maternal physiology.
Choice C: This is incorrect because antihypertensive medications are not a cure for preeclampsia, but a symptomatic management. Antihypertensive medications may lower the blood pressure and reduce the risk of maternal complications, such as stroke, seizure, or organ damage. However, antihypertensive medications do not address the underlying cause of preeclampsia and do not improve fetal outcomes. Moreover, some antihypertensive medications are contraindicated in pregnancy due to their teratogenic effects.
Choice D: This is incorrect because magnesium sulfate is not a cure for preeclampsia, but a prophylaxis for eclampsia. Eclampsia is a severe complication of preeclampsia that involves seizures and coma. Magnesium sulfate is an anticonvulsant that prevents or treats eclamptic seizures by stabilizing neuronal membranes and reducing cerebral edema. However, magnesium sulfate does not lower blood pressure or improve renal function in preeclamptic women. It also has side effects such as nausea, flushing, headache, or respiratory depression.
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