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 D
Explanation
Choice a) Ectopic pregnancy is incorrect because this is not a condition that requires delivery by cesarean section. Ectopic pregnancy is a condition where the fertilized egg implants outside the uterus, usually in the fallopian tube. It is a life-threatening complication that can cause internal bleeding and rupture of the tube. Ectopic pregnancy cannot result in a viable baby and must be terminated as soon as possible, either by medication or surgery. Therefore, this response is irrelevant and inaccurate.
Choice b) Preeclampsia is incorrect because this is not a condition that always necessitates delivery by cesarean section. Preeclampsia is a condition where the blood pressure rises above 140/90 mmHg after 20 weeks of pregnancy, along with proteinuria and edema. It can cause complications such as eclampsia, HELLP syndrome, placental abruption, and fetal growth restriction. The only cure for preeclampsia is delivery of the baby and placenta, but the mode of delivery depends on several factors, such as the gestational age, the severity of the condition, the fetal status, and the maternal preference. Therefore, some women with preeclampsia may deliver vaginally, while
others may need a cesarean section.
Choice c) Partial abruptio placentae is incorrect because this is not a condition that always necessitates delivery by cesarean section. Abruptio placentae is a condition where the placenta separates from the uterine wall before delivery, causing vaginal bleeding, abdominal pain, uterine contractions, and fetal distress. It can be classified as partial or complete, depending on the extent of the separation. The mode of delivery for abruptio placentae depends on several factors, such as the degree of bleeding, the fetal viability, the cervical dilation, and the fetal position.
Therefore, some women with partial abruptio placentae may deliver vaginally, while others may need a cesarean section.
Choice d) Total placenta previa is correct because this is the only condition that always necessitates delivery by cesarean section. Placenta previa is a condition where the placenta covers part or all of the cervix, preventing normal delivery. It can be classified as marginal, partial, or total, depending on the degree of overlap. The mode of delivery for placenta previa depends on several factors, such as the type of previa, the amount of bleeding, the gestational age, and the fetal status. However, women with total placenta previa have no chance of delivering vaginally, as the placenta completely blocks the birth canal. Therefore, they must have a cesarean section to avoid hemorrhage and fetal compromise.
Correct Answer is A
Explanation
Choice a) This could result in profound bleeding is correct because this is the primary reason why an internal examination should be avoided for a client who has placenta previa. Placenta previa is a condition where the placenta covers part or all of the cervix, preventing normal delivery. An internal examination involves inserting a gloved finger or a speculum into the vagina and cervix to assess their dilation, effacement, position, and station. This can cause trauma to the cervix or the placenta, which can trigger severe hemorrhage and endanger the mother and the fetus. Therefore, this explanation is accurate and appropriate.
Choice b) This could initiate preterm labor is incorrect because this is not the main reason why an internal examination should be avoided for a client who has placenta previa. Placenta previa is a condition where the placenta covers part or all of the cervix, preventing normal delivery. An internal examination may stimulate uterine contractions, which can lead to preterm labor and delivery. However, this is not the most serious or likely complication of an internal examination for a client who has placenta previa, as the bleeding risk is much higher and more urgent. Therefore, this explanation is incomplete and misleading.
Choice c) There is an increased risk of introducing infection is incorrect because this is not a specific reason why an internal examination should be avoided for a client who has placenta previa. Placenta previa is a condition where the placenta covers part or all of the cervix, preventing normal delivery. An internal examination may introduce bacteria or other microorganisms into the vagina or cervix, which can cause infection and inflammation. However, this is a general risk that applies to any pregnant woman who undergoes an internal examination, not just those who have placenta previa. Therefore, this explanation is irrelevant and inaccurate.
Choice d) There is an increased risk of rupture of the membranes is incorrect because this is not a relevant reason why an internal examination should be avoided for a client who has placenta previa. Placenta previa is a condition where the placenta covers part or all of the cervix, preventing normal delivery. An internal examination may cause rupture of the membranes, which are the sacs that contain the amniotic fluid and the fetus. However, this is not a significant or common complication of an internal examination for a client who has placenta previa, as the membranes are usually located above or away from the placenta and cervix. Therefore, this explanation is improbable and inaccurate.
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