Which assessment finding if present on the second day after a normal vaginal delivery would indicate that involution was not occurring satisfactorily?
a. Fundal height two fingerwidths above the umbilicus
b. Peripad changed every 4 to 5 hours with reddish, brown blood
c. Red clot, 2-centimeter diameter, expelled from vagina while urinating
d. Urination of blood-tinged urine
A
Fundal height two fingerwidths above the umbilicus indicates bladder distention. The normal fundal height on the second day postpartum should be 3 to 4 cm below the level of the umbilicus. Peripad changed every 4 to 5 hours with reddish, brown blood is a normal finding as the lochia is beginning the transition from rubra to serosa. Red clot, 2-centimeter diameter, expelled from vagina while urinating is a normal finding after lying down and then sitting, standing, or ambulating, due to the pooled vagina discharge being expelled. Blood-tinged urine is usually the result of urine mixing with lochia during urination.
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