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
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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Related Questions
Correct Answer is C
Explanation
A. Detection of a fetal heartbeat by ultrasound is a positive sign of pregnancy because it provides direct, objective evidence of a living fetus. Positive signs can only be attributed to pregnancy and include fetal heart tones, visualization of the fetus, and fetal movements palpated by the examiner.
B. A positive pregnancy test is a probable sign of pregnancy. It detects human chorionic gonadotropin (hCG) in blood or urine, which is usually produced during pregnancy, but false positives can occur due to hCG-secreting tumors, recent pregnancy loss, or fertility medications.
C. Breast tenderness and enlargement are presumptive signs of pregnancy. Presumptive signs are subjective symptoms reported by the woman and are not diagnostic. They result from early hormonal changes (increased estrogen and progesterone) and may also occur with premenstrual syndrome or hormonal imbalances, making them non-specific to pregnancy.
D. Abdominal enlargement is a probable sign of pregnancy because it is an objective finding observed by the healthcare provider but can be caused by other conditions such as obesity, uterine fibroids, ovarian tumors, or ascites.
Correct Answer is D
Explanation
A. 4 is incorrect because the infant demonstrates more than minimal findings across several Apgar components, resulting in a higher score than 4.
B. 7 is incorrect because a score of 7 would require stronger respiratory effort (good cry) or a heart rate above 100 beats per minute, which are not present in this assessment.
C. 5 is incorrect because the infant earns more points based on reflex irritability and overall appearance, making the score higher than 5.
D. 6 is correct because the Apgar score is calculated as follows:
- Heart rate of 90 beats per minute = 1 point
- Weak cry = 1 point
- Some flexion of extremities = 1 point
- Prompt response to stimuli = 2 points
- Pink body with blue extremities (acrocyanosis) = 1 point
The total Apgar score at 1 minute is 6.
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