Which documentation on a woman's chart after postpartum day 14 indicates a normal involution process?

Fundus below the symphysis and not palpable

Moderate, bright red lochia.

Breasts warm, firm and tender

Laceration slightly red and puffy

Answer and Explanation

The Correct Answer is A

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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A) The neonate with respirations of 78 and a heart rate of 176:
This is the most concerning finding and requires immediate evaluation. Normal respiratory rate for a newborn is typically between 30 and 60 breaths per minute, so a rate of 78 breaths per minute is significantly elevated, indicating potential respiratory distress. Additionally, a heart rate of 176 beats per minute, while somewhat elevated, could indicate tachycardia, especially if the baby is experiencing distress or inadequate oxygenation. This combination of abnormal vital signs may point to respiratory or cardiovascular compromise, such as respiratory distress syndrome or other neonatal respiratory issues, which requires immediate evaluation and intervention.

B) The neonate with a temperature of 99.1°F and a weight of 3000 grams:
This neonate’s temperature is within the normal range (97.7°F to 99.5°F), and a weight of 3000 grams is also considered appropriate for a full-term newborn. These findings do not raise any immediate concerns, and no further action is necessary based on these observations alone.

C) The neonate with raised white specks on the gums:
Raised white specks or nodules on the gums are often a normal finding in newborns and are called Epstein pearls. These are benign cystic formations that do not require treatment. They are not a cause for concern and are common in newborns, usually disappearing on their own within a few weeks.

D) The neonate with white spots on the bridge of the nose:
White spots on the nose are likely to be Milia, which are small, benign cysts commonly seen on the face of newborns, particularly on the nose, cheeks, and chin. Milia are harmless and typically resolve without treatment within a few weeks. There is no need for concern in this case.

A. Babinski Reflex B. Rooting C. Plantar Flexion D. Moro

Correct Answer is A

Explanation

The Babinski reflex is present in newborns and occurs when the sole of the foot is stroked from heel to toe. The infant's big toe dorsiflexes (moves upward) and the other toes fan out. This is a normal response in infants up to 12-24 months but is abnormal in older children and adults, where it may indicate neurological issues.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Which documentation on a woman's chart after postpartum day 14 indicates a normal involution process?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Four newborns were admitted into the neonatal nursery 1 hour ago. They are all sleeping in overhead warmers. Which of the babies should the nurse ask the neonatologist to evaluate?

Correct Answer is A

Explanation

When the infant's toes hyperextend and the big toe dorsiflexes when sole of foot is stroked. This Reflex is called

Correct Answer is A

Explanation

The nurse is going to administer a dose of Vitamin K (Aquamephyton) 0.5mg IM to a newborn. Available: Vitamin K 1 mg/1ml. How many mLs would the nurse administer? (Please answer numerically only)

A postpartum woman telephones about her 6-day-old infant. She is not scheduled for, weight check until the infant is 10 days old, and she is worried about whether breastfeeding going well. Effective breastfeeding is best indicated by the newborn who:

The most important reason to protect the preterm infant from cold stress is that:

Which documentation on a woman's chart after postpartum day 14 indicates a normal involution process?

A nurse is giving discharge instructions to a new mother. What is the most important instruction to address the prevention of postpartum infection?

At 1 minute after birth the nurse assesses the newborn and notes the following: Heart rate: 80 beats/minute Respiratory effort: slow, irregular Muscle tone: some flexion of extremities Reflex irritability: grimacing Color: blue and pale The nurse would calculate an Apgar score of:

Rho immune globulin (Rhogam) will be ordered postpartum if which situation occurs?