Which documentation on a woman's chart after postpartum day 14 indicates a normal involution process?

Fundus below the symphysis and not palpable

Moderate, bright red lochia.

Breasts warm, firm and tender

Laceration slightly red and puffy

Answer and Explanation

The Correct Answer is A

A) Fundus below the symphysis and not palpable:
The process of involution refers to the shrinking and returning of the uterus to its normal size and position after delivery. By postpartum day 14, the uterus should be largely involuted, with the fundus no longer palpable above the pubic symphysis. This is a normal finding, as the uterus typically shrinks to its pre-pregnancy size over this period. The fundus should be at or below the symphysis pubis and should not be palpable after about two weeks postpartum, indicating that the involution process is proceeding as expected.

B) Moderate, bright red lochia:
While bright red lochia (also known as lochia rubra) is common during the first few days postpartum, by postpartum day 14, lochia should have transitioned to a serosa (pinkish or brownish) or alba (white or yellowish) appearance. Bright red lochia on day 14 would suggest a possible issue, such as retained placental fragments or uterine atony, and would require further evaluation.

C) Breasts warm, firm and tender:
Breast tenderness and firmness can be normal in the early postpartum period, especially as milk comes in. However, by postpartum day 14, if the breasts remain tender and warm, this could indicate mastitis or engorgement that hasn't been resolved. While some tenderness may still occur, it should have decreased by this point. If tenderness persists, further assessment would be needed.

D) Laceration slightly red and puffy:
Postpartum lacerations or episiotomy sites should begin to heal within the first few days, but slight redness and swelling might still be present at two weeks. However, puffiness or continued redness after 14 days may indicate poor healing, infection, or other complications, which requires further evaluation and intervention. Normal healing should show a decrease in redness and swelling by this time.

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Correct Answer is ["4"]

Explanation

The Apgar score is calculated based on five criteria, each scored from 0 to 2:

Heart rate
- 0 = Absent
- 1 = Below 100 beats per minute ✅
- 2 = 100 or more beats per minute
Respiratory effort
- 0 = Absent
- 1 = Slow, irregular ✅
- 2 = Good, crying
Muscle tone
- 0 = Limp
- 1 = Some flexion of extremities ✅
- 2 = Active motion
Reflex irritability (response to stimulation, e.g., suctioning)
- 0 = No response
- 1 = Grimace ✅
- 2 = Crying, active withdrawal
Color
- 0 = Blue, pale
- 1 = Body pink, extremities blue
- 2 = Completely pink

Apgar Score Calculation:

Heart rate: 1
Respiratory effort: 1
Muscle tone: 1
Reflex irritability: 1
Color: 0

Total Apgar Score: 4

A score of 4 suggests the newborn is in distress and requires immediate medical intervention, such as oxygen support and further assessment.

A. Intracostal retractions B. Caput succedaneum C. Positive Babinski sign D. Pink-tinged urine in the diaper

Correct Answer is A

Explanation

A) Intracostal retractions:
Intracostal retractions indicate respiratory distress in the newborn and should be reported immediately to the neonatologist. Retractions occur when the muscles between the ribs (intercostal muscles) are drawn in with each breath, signifying increased effort to breathe. This could indicate a serious condition such as respiratory distress syndrome (RDS), pneumonia, or other respiratory compromise. This finding requires urgent assessment and potential intervention to ensure the neonate is receiving adequate oxygenation.

B) Caput succedaneum:
Caput succedaneum is a common and benign finding in newborns, especially after a vaginal delivery. It refers to a swelling of the soft tissue on the baby's head, often seen after prolonged labor or use of forceps during delivery. This condition is typically resolves on its own within a few days and does not require immediate intervention or reporting to the neonatologist.

C) Positive Babinski sign:
A positive Babinski sign (fanning of the toes when the sole is stroked) is a normal reflex in neonates and is expected up to about 2 years of age. It is part of the newborn's neurological development and indicates the functioning of the central nervous system. Therefore, this finding does not require reporting to the neonatologist.

D) Pink-tinged urine in the diaper:
Pink-tinged urine, also known as "brick dust" or uric acid crystals, is a common finding in the first few days of life. It is typically harmless and results from concentrated urine or from the breakdown of urates. It usually resolves as the newborn begins to consume more fluids and the urine becomes more diluted. This finding does not necessitate immediate reporting unless it persists or is associated with other symptoms.

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Which documentation on a woman's chart after postpartum day 14 indicates a normal involution process?

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Naxlex Comprehensive Predictor Exams

At 1 minute after birth the nurse assesses the newborn and notes the following: Heart rate: 80 beats/minute Respiratory effort: slow, irregular Muscle tone: some flexion of extremities Reflex irritability: grimacing Color: blue and pale The nurse would calculate an Apgar score of:

Correct Answer is ["4"]

Explanation

Apgar Score Calculation:

A nurse is assessing a newborn at 2 hours of life. Which of the following findings should the nurse report to the neonatologist?

Correct Answer is A

Explanation

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