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

Moderate bright red lochial flow

Fundus below the symphysis and nonpalpable

Episiotomy slightly red and puffy

Breasts firm and tender

Answer and Explanation

The Correct Answer is B

A.   Moderate bright red lochial flow on postpartum day 14 may indicate excessive bleeding and is not indicative of normal involution.
B.   A fundus below the symphysis and nonpalpable suggests a well-contracted uterus, which is indicative of normal involution.
C. An episiotomy that is slightly red and puffy on day 14 may indicate ongoing healing, but it is not a direct measure of uterine involution.
D.   Breasts that are firm and tender on postpartum day 14 may indicate engorgement, but they are not directly related to uterine involution.

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Correct Answer is A

Explanation

A. Assessing for respiratory distress is the priority as the newborn's ability to breathe independently is crucial immediately after birth.
B. Acrocyanosis is a common and expected finding in newborns, especially in the first few hours after birth.
C. Accidental lacerations, while important to assess, are not as immediately critical as respiratory distress.
D. While hypothermia is a concern, addressing respiratory distress takes precedence in the immediate postoperative period.

A. “This is a cephalhematoma, which can occur spontaneously.” B. “Caput succedaneum occurs due to compression of blood vessels.” C. “This is erythema toxicum, which is a transient condition.” D. “Mongolian spots can be found on the skin of many newborns.”

Correct Answer is B

Explanation

A. A cephalhematoma is a collection of blood under the periosteum that does not cross the suture lines and can take weeks to resolve.
B. Caput succedaneum occurs due to compression of blood vessels during delivery, resulting in edema and bruising of the scalp. It crosses the suture lines and usually resolves within a few days and does not cause any complications.
C. Erythema toxicum is a rash that is unrelated to head swelling.
D. Mongolian spots are blue-gray patches on the skin, not associated with head swelling.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a newborn immediately following a scheduled cesarean delivery. Which of the following assessments is the nurse’s priority?

Correct Answer is A

Explanation

A nurse is caring for a newborn delivered by vaginal birth with a vacuum assist. The newborn’s mother asks about the swollen area on her son’s head. After palpation to identify that the swelling crosses the suture line, which of the following is an appropriate response by the nurse?

Correct Answer is B

Explanation

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