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) A phase of the female menstrual cycle that involves the release of an egg (ovum) from one of the ovaries is incorrect because this is not the definition of Mittelschmerz, but rather the definition of ovulation. Ovulation is the process by which one or more eggs are released from the ovaries and travel to the fallopian tubes, where they can be fertilized by sperm. Ovulation usually occurs around the middle of the menstrual cycle, which is typically 28 days long, but can vary from person to person. Ovulation can be detected by changes in basal body temperature, cervical mucus, or hormone levels. Therefore, this response is inaccurate and misleading.
Choice B) A female reproductive organ in which ova or eggs are produced is incorrect because this is not the definition of Mittelschmerz, but rather the definition of ovary. The ovary is a paired organ that is located on either side of the uterus in the lower abdomen. The ovary contains thousands of follicles, which are sacs that contain immature eggs. Each month, one or more follicles mature and release an egg during ovulation. The ovary also produces hormones such as estrogen and progesterone, which regulate the menstrual cycle and pregnancy. Therefore, this response is irrelevant and inaccurate.
Choice C) The regular discharge of blood and mucosal tissue from the inner lining of the uterus through the vagina is incorrect because this is not the definition of Mittelschmerz, but rather the definition of menstruation. Menstruation is the process by which the endometrium, which is the tissue that lines the uterus and prepares for implantation of a fertilized egg, is shed and expelled through the vagina if pregnancy does not occur. Menstruation usually occurs once a month and lasts for about 3 to 7 days, but can vary from person to person. Menstruation can be accompanied by symptoms such as cramps, bloating, mood swings, or headaches. Therefore, this response is irrelevant and inaccurate.
Choice D) One-sided, lower belly pain associated with normal ovulation. Usually occurs about 14 days before the next menstrual period is correct because this is the definition of Mittelschmerz. Mittelschmerz is a German word that means "middle pain". It refers to a mild to moderate pain or discomfort that some women experience in their lower abdomen around the time of ovulation. The pain may last for a few minutes to a few hours and may switch sides from month to month depending on which ovary releases an egg. The pain may be caused by irritation or stretching of the ovarian or abdominal wall by the maturing follicle or by fluid or blood released during ovulation.
Mittelschmerz is not a sign of any disease or problem and does not require any treatment. However, it can be confused with other conditions that cause pelvic pain, such as appendicitis, ectopic pregnancy, or ovarian cysts. Therefore, women who have severe or persistent pain should consult their doctor for diagnosis and treatment. Therefore, this response is clear and accurate.
Correct Answer is D
Explanation
Choice a) We are protecting the infant from our bacteria is incorrect because this is not the main reason why gloves are needed when handling a newborn. While it is true that newborns have immature immune systems and are susceptible to infections, gloves are not only used to protect the infant from our bacteria but also to protect ourselves from the infant's body fluids and secretions, which may contain pathogens or blood-borne diseases.
Therefore, this response is incomplete and misleading.
Choice b) Amniotic fluid and maternal blood pose risks to us is incorrect because this is also not the primary reason why gloves are needed when handling a newborn. While it is true that amniotic fluid and maternal blood may contain harmful microorganisms or viruses that can infect us, gloves are not only used to protect ourselves from these substances but also to protect the infant from our skin flora and potential contaminants, which may cause skin irritation or infection. Therefore, this response is also incomplete and misleading.
Choice c) It is hospital policy is incorrect because this is not a sufficient or satisfactory reason why gloves are needed when handling a newborn. While it is true that wearing gloves may be a hospital policy or protocol, this response does not explain the rationale or evidence behind this policy and may imply that the nurse does not understand or agree with it. Therefore, this response is vague and unprofessional.
Choice d) It is part of standard precautions is correct because this is the best and most accurate reason why gloves are needed when handling a newborn. Standard precautions are a set of guidelines and practices that aim to prevent the transmission of infections in healthcare settings. They include wearing gloves, gowns, masks, and eye protection when there is a risk of exposure to blood or body fluids, as well as washing hands before and after patient contact, cleaning and disinfecting equipment and surfaces, and disposing of waste properly. Standard precautions apply to all patients, regardless of their diagnosis or infection status, and are based on the principle that all blood and body fluids are potentially infectious. Therefore, this response is clear and appropriate.
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