A 28 year old G1 delivered 16 hours ago via forceps assisted vaginal delivery of a 9lb 2 oz male infant with a 4th degree repair.

Estimated blood loss (EBL) was 378 mL. She was in the second stage of labor for 3.5 hours and is very sore and swollen.

Vital signs are within normal limits and she reports her pain at 6/10. She is ambulating and last voided 300 cc of clear yellow urine 4 hours ago.

Bowel sounds are active and she is passing gas but has had no bowel movement since delivery.

The nurse understands that a 4th degree laceration tore through the rectal wall and anal sphincter and that the patient will need to:

Choice A rationale

The uterus is generally no longer palpable abdominally by about 10 to 14 days postpartum, as it descends back into the true pelvis. Therefore, a non-palpable uterus by week 2 (14 days) is often a normal finding, not one that strongly suggests subinvolution, which is a slower-than-expected return to the non-pregnant state.

Choice B rationale

Lochia serosa (pinkish-brown discharge) typically appears around day 4 or 5 and may last until about the tenth day. Its presence on day 5 is within the expected timeline of normal involution. Subinvolution is often characterized by prolonged or excessive lochia (rubra or serosa) beyond the normal time frame.

Choice C rationale

The fundus is typically located 1-2 cm below the umbilicus by 24 hours postpartum and descends approximately 1 fingerbreadth (1 cm) per day. A fundus 2 cm below the umbilicus on day 3 is consistent with the expected rate of involution, suggesting a normal progression, not subinvolution.

Choice D rationale

The uterus is typically at or below the symphysis pubis and no longer palpable abdominally by day 10. A uterus palpable above the umbilicus on day 7 indicates that the rate of descent is slower than expected (it should be much lower), which is the hallmark sign of subinvolution. .

Choice A rationale

The fetal heart rate (FHR) strip shows minimal variability (amplitude changes of 5 beats per minute or less), indicating potential fetal hypoxia or metabolic acidemia. Late decelerations are present, characterized by a gradual decrease in FHR beginning after the peak of the contraction and returning to baseline after the contraction ends, indicating uteroplacental insufficiency. This pattern is non-reassuring, requiring immediate intrauterine resuscitation measures (fluids, oxygen, repositioning) and provider notification. —.

Choice B rationale

Moderate variability would show an amplitude range of 6 to 25 beats per minute, which is not seen on this strip, classifying it as minimal. Early decelerations mirror the contraction, starting before or at the beginning of the contraction and returning to baseline by the end, typically indicating head compression and being benign, unlike the late decelerations visible. —.

Choice C rationale

Moderate variability is defined as an amplitude range of 6 to 25 beats per minute, which is absent here. Variable decelerations are an abrupt decrease in FHR, often U, V, or W-shaped, and vary in timing relative to contractions, reflecting cord compression. This strip shows late decelerations which are gradual and signify a more concerning issue of uteroplacental insufficiency. —.

Choice D rationale

The strip shows minimal variability (amplitude ≤ 5 bpm), indicating potential compromise, so continued monitoring alone is insufficient and potentially dangerous. Accelerations are abrupt increases in FHR above the baseline (at least 15 bpm for at least 15 seconds, or 10 × 10 for preterm), which are reassuring and not seen here. The presence of late decelerations necessitates immediate intervention.