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","C","D"]

Explanation

A. Microwaving breast milk decreases vitamin C content.
B. Microwaving does not render the milk tasteless, but it may alter the taste slightly.
C. Microwaving does not heat breast milk evenly, creating hot spots that can burn the baby's mouth.
D. Microwaving can decrease the antiinfective properties of breast milk.
E. Microwaving breast milk does not decrease iron content.

A. Change the perineal pad of a client who just transferred from labor and delivery. B. Monitor vital signs during admission of a client who has gestational hypertension. C. Provide a sitz bath to a client who has a fourth-degree laceration and is 2 days postpartum. D. Observe an area of redness on the breast of a client who is 1 day postpartum.

Correct Answer is C

Explanation

A. Changing the perineal pad of a client who has just been transferred from the labor ward is a task that should not be delegated to an assistive personnel (AP) since it is beyond their scope.
B. Monitoring vital signs during the admission of a client with gestational hypertension requires nursing judgment and assessment skills.
C. Providing a sitz bath to a client with a fourth-degree laceration and is 2 days post- partum can be delegated to an AP. This task does not require the nurse's clinical judgment or assessment skills, and it can be safely performed by the AP following the nurse's instructions.
D. Observing an area of redness on the breast requires nursing assessment and intervention.

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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 teaching a new mother the best method to store milk and use it later for feeding. She explains that the breast milk should never be thawed or heated in a microwave oven because of the following reasons. Please select all that apply

Correct Answer is ["A","C","D"]

Explanation

A nurse on the postpartum unit is caring for a group of clients with an assistive personnel (AP). Which of the following tasks should the nurse plan to delegate to the AP?

Correct Answer is C

Explanation

While evaluating the reflexes of a newborn, the nurse notes that with a loud noise the newborn symmetrically abducts and extends his arms, his fingers fan out and form a C with the thumb and forefinger, and he has a slight tremor. The nurse would document this finding as a positive reflex.

A nurse is assisting with the care of a newborn immediately following birth. Which of the following medications should the nurse anticipate administering? (Select all that apply.)

A nurse is planning care for a client who is 2 hours postpartum following a cesarean birth. The client has a history of thromboembolic disease. Which of the following nursing interventions should be included in the plan of care?

A new mother states that her infant must be cold because the baby’s hands and feet are blue. This common and temporary condition is called what?

A new mother asks the nurse what the "experts say" about the best way to feed her infant. Which recommendation of the American Academy of Pediatrics (AAP) regarding infant nutrition should be shared with this client?

A nurse in the newborn nursery is caring for a group of newborns. Which of the following newborns requires immediate intervention?

A nurse is caring for a client who reports unrelieved episiotomy pain 8 hr following a vaginal birth. Which of the following actions should the nurse take?