Which statement should the nurse document on a woman's chart who is postpartum day 14 that indicates normal involution?

Fundus is midway between the umbilicus and symphysis pubis, 16-week size

Episiotomy slightly red and puffy

Moderate bright red lochial flow

Fundus below the symphysis pubis and nonpalpable

Answer and Explanation

The Correct Answer is D

A. At 14 days postpartum, the uterus should have completed most of its involution and should no longer be palpable abdominally. A fundus midway between the symphysis and umbilicus indicates the uterus is still enlarged, which is normal only in the first week postpartum.

B. Mild redness may be expected in the first few days after birth, but by day 14, the perineum should be healed without significant redness, swelling, or tenderness. Redness and puffiness at this stage could indicate infection or delayed healing.

C. By two weeks postpartum, lochial flow should have transitioned to serous or serosanguineous (lochia serosa) and be scant. Bright red, moderate lochia at day 14 may suggest delayed involution or secondary hemorrhage.

D. By approximately 2 weeks postpartum, the uterus has usually involuted to its pre-pregnancy size and descends into the pelvic cavity, becoming nonpalpable abdominally. This finding indicates normal uterine involution, a key aspect of postpartum recovery.

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Correct Answer is A

Explanation

A. Abnormal uterine bleeding (AUB) refers to bleeding from the uterus that is irregular in volume, duration, or timing and is not related to normal menstruation. This definition makes “mostly irregular uterine bleeding” the most accurate description.
B. AUB originates from the uterus, not the ovaries. While ovarian dysfunction can contribute to AUB, the bleeding itself is classified based on uterine patterns, not ovarian activity.
C. AUB is irregular and does not follow the typical monthly menstrual cycle. It may occur unpredictably or with excessive or prolonged bleeding.
D. Steroids are not the primary treatment for AUB. Medical management usually includes hormonal therapies such as combined oral contraceptives, progestins, or tranexamic acid depending on the underlying cause.

A. Call the provider to further assess the newborn. B. Ask another nurse to verify the heart rate. C. Document this as an expected finding. D. Prepare the newborn for transport to the NICU.

Correct Answer is C

Explanation

A. This is not necessary in this situation because a heart rate of 130 beats per minute is within the normal range for a term newborn. Immediate notification of the provider is required only for abnormal heart rates (tachycardia >160 bpm, bradycardia <100 bpm), irregular rhythms, or other signs of compromise, such as pallor, cyanosis, or poor perfusion.

B. Verification may be useful when an abnormal or unexpected finding occurs, but it is not required for a heart rate that is clearly within the normal range. Routine newborn assessments are reliable when performed properly.

C. The normal resting heart rate for a full-term newborn ranges from 110 to 160 beats per minute. A heart rate of 130/min falls squarely within this range, indicating adequate cardiovascular function. Documentation should include the apical heart rate, method of measurement, time of assessment, and any relevant observations (e.g., skin color, activity, respiratory effort). Proper documentation ensures continuity of care and provides a baseline for ongoing assessments.

D. This is unnecessary. There are no signs of distress or abnormal findings in this scenario that would warrant NICU admission. Routine monitoring and care in the newborn nursery or with the mother are appropriate.

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Which statement should the nurse document on a woman's chart who is postpartum day 14 that indicates normal involution?

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Naxlex Comprehensive Predictor Exams

Which statement regarding abnormal uterine bleeding (AUB) is most accurate?

Correct Answer is A

Explanation

A nurse is caring for a newborn and auscultates an apical heart rate of 130/min. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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