A nurse is assessing a postpartum client 24 hours after vaginal delivery. Which assessment finding requires immediate nursing intervention?
1Lochia rubra with small clots and mild cramping during breastfeeding
2Fundus located 3 cm above the umbilicus and displaced to the right side✓ 정답
3Breast engorgement with bilateral tenderness and warmth
4Perineal edema with intact sutures and no signs of infection
해설
A fundus 3 cm above umbilicus and displaced right indicates uterine subinvolution and bladder distention, requiring immediate intervention to prevent hemorrhage. Other findings are normal postpartum variations.
Clinical Judgment
This question assesses your ability to set priorities in identifying early postpartum complications. The key is to know the normal postpartum recovery process and to catch danger signs that deviate from it. 24 hours after delivery, the fundus should normally be located at the level of the umbilicus or begin to descend slightly below it, and it should be on the midline. In option 2, "3 cm above the umbilicus" means the uterus is contracting more slowly than expected (Subinvolution), and "displaced to the right side" is a critical clue that the bladder is very likely full and pushing the uterus aside. A full bladder prevents the uterus from contracting properly, making it a major risk factor for Postpartum Hemorrhage. Therefore, this finding requires immediate intervention to help empty the bladder and reassess uterine contraction status.
Memory Tip
Mnemonic for fundal position: Fundus Umbilicus Daily Descends (FUDD). After delivery, the fundus descends about 1 cm (or one finger's breadth) daily. At 24 hours, the level of the umbilicus (U) is normal. If it is "Up and Off-center," it is an Urgent sign.
KR vs US
The importance of postpartum fundal assessment and bladder management is the same in both Korea and the US. However, the US NGN places greater emphasis on Clinical Judgment, which clearly distinguishes between this 'normal vs. abnormal' determination and the resulting priority of nursing interventions. A specific action to eliminate a 'currently present' risk factor (a full bladder) takes priority over monitoring for a 'possible' complication.
Clinical Practice GuideWhen assessing the uterine fundus within 24 hours postpartum, systematically evaluate: 1) position (how many cm above or below the umbilicus), 2) consistency (firm or boggy), and 3) location (midline or deviated). If a right-deviated uterine fundus is found, the first intervention is to encourage voiding or consider catheter insertion. After emptying the bladder, reassess the fundal position and consistency.CautionIn SATA (Select All That Apply) questions, when choosing "interventions needed immediately," beware of traps that include normal or expected discomforts such as option 1 (lochia, small clots) or option 3 (breast engorgement). A "deviated uterine fundus" is a high-risk finding almost always included in the correct answer list.
Fundal Assessment (자궁저부 사정) — Assessment of uterine fundal height, firmness, and position (midline) to evaluate uterine contraction and involution after delivery. Key to preventing postpartum hemorrhage.
Subinvolution of the Uterus (자궁복구부전) — A condition where the uterus does not return to its pre-pregnancy size and condition at a normal rate after delivery. The uterine fundus remains higher than expected, and it may be accompanied by persistent or excessive lochia bleeding, making it a risk factor for postpartum hemorrhage.
Bladder Distention (방광 팽만) — Bladder is full of urine and distended. In the early postpartum period, it can easily occur due to dulled bladder sensation caused by perineal pain, medications, anesthesia, etc., and it displaces the uterus, interfering with contractions.
Lochia Rubra (로키아 루브라) — Bright red, bloody uterine discharge that continues for the first 3–4 days after delivery. It may contain small blood clots, and its amount and color gradually change (lochia serosa, lochia alba).
Postpartum Hemorrhage (PPH, 산후출혈) — Excessive bleeding of 500mL or more (vaginal delivery) or 1000mL or more (cesarean section) occurring within 24 hours after delivery. Uterine atony is the most common cause, and bladder distension is a factor that can trigger or worsen it.