A postpartum client who delivered vaginally 8 hours ago is experiencing heavy vaginal bleeding with clots larger than a quarter. Her fundus is boggy and located 2 cm above the umbilicus. Vital signs are: BP 90/60 mmHg, HR 110 bpm, RR 22/min. What is the nurse's priority intervention?
1Perform fundal massage and assess for bladder distention✓ 정답
2Administer prescribed pain medication for comfort
3Encourage the client to ambulate to the bathroom
4Document findings and notify the healthcare provider
해설
Fundal massage is the priority to stimulate uterine contractions and control bleeding in postpartum hemorrhage with uterine atony. Other options address comfort or documentation but do not manage the immediate life-threatening bleeding.
Clinical Presentation Analysis
The client is demonstrating classic signs of early postpartum hemorrhage (PPH), most likely due to uterine atony. The assessment reveals a boggy uterus on palpation, which indicates the myometrium is not contracting effectively to compress the spiral arteries at the placental site [1,2]. The fundal height is 2 cm above the umbilicus, which is an abnormal finding at 8 hours postpartum; a firm, contracted uterus should be located at or below the umbilicus. This upward displacement strongly suggests bladder distention, a mechanical factor that can displace the uterus and prevent effective contraction. The vital signs—BP 90/60 mmHg (hypotension) and HR 110 bpm (tachycardia)—are compensatory mechanisms for hypovolemia, indicating a significant volume of blood loss has already occurred [4]. The presence of clots larger than a quarter confirms active, heavy bleeding.
Priority Intervention Rationale
The nurse's priority intervention is to perform fundal massage and assess for bladder distention. This directly addresses the most common and reversible cause of PPH: uterine atony [1,3]. The stepwise management of PPH begins with immediate, non-invasive mechanical and physiological maneuvers before escalating to pharmacological or surgical interventions [1,4]. Fundal massage provides direct tactile stimulation to the uterine muscle, promoting contraction and expulsion of accumulated blood clots that may be inhibiting the process [3]. Simultaneously, assessing for and relieving bladder distention is critical because a full bladder mechanically obstructs uterine descent and contraction. The combination of these two actions targets both the primary physiological dysfunction (atony) and a common contributing mechanical factor, making it the most time-sensitive and independent nursing action to control hemorrhage at the bedside.
Analysis of Incorrect Options
Administering prescribed pain medication (Option 2) is not the priority. While pain can contribute to sympathetic nervous system activation, it is not the direct cause of the hemorrhage, and administering an analgesic does not control the active bleeding or stabilize hemodynamics. Encouraging ambulation (Option 3) is contraindicated in a client with active, heavy bleeding and signs of hypovolemia due to the high risk of orthostatic hypotension, syncope, and falls. While documenting findings and notifying the healthcare provider (Option 4) are essential nursing responsibilities, they are secondary to implementing an immediate, life-saving intervention. The nurse must act to control the bleeding first, as delays to document or wait for a provider’s order for a basic intervention like fundal massage can lead to worsening hemorrhage and clinical deterioration [4]. The initial management of uterine atony, including fundal massage, is a core, independent nursing intervention that should not be deferred.
References (research sources)
[3]
The effects of breastfeeding, uterine massage, perineal protective approaches in preventing postpartum hemorrhage in perinatal period: Comparative controlled clinical study.Research articlePeksoy Kaya S, Terzioglu F. (2026) · DOI: 10.1097/md.0000000000048066
[4]
Postpartum Haemorrhage Burden, Management and Challenges in Malaysia: A Scoping Review and Expert Recommendations for Effective Management.GuidelineHamdan M, Lim C, Tang BN, Abdul Hamid H, Narayanan V, Abdul Ghani NA, Ismail MP, Selvaratnam V, Wadhawan S, Mukherjee D. (2025) · DOI: 10.7759/cureus.89915
Clinical Management of Early Postpartum Hemorrhage
A postpartum client 8 hours post-vaginal delivery presents with heavy vaginal bleeding, clots larger than a quarter, a boggy fundus displaced 2 cm above the umbilicus, and signs of hypovolemic shock (BP 90/60 mmHg, HR 110 bpm).
Immediate Nursing Actions
Fundal Massage: Immediately perform firm, one-handed fundal massage to stimulate uterine contraction and expel clots. Support the lower uterine segment with the other hand to prevent inversion.
Bladder Assessment: Assess for bladder distention, a common cause of uterine displacement and atony. Assist the client to void or perform straight catheterization if unable to void spontaneously.
Call for Help: Activate the facility's obstetric emergency protocol and delegate a team member to notify the healthcare provider while you remain with the client.
Ongoing Monitoring
Reassess fundal tone and location every 5-15 minutes after massage. A firm, midline uterus at or below the umbilicus indicates a positive response.
Quantify blood loss by weighing pads and linens (1 gram = 1 mL blood loss).
Continuously monitor vital signs, oxygen saturation, and level of consciousness for signs of worsening shock.
Prepare for pharmacological interventions (e.g., oxytocin, methylergonovine) as prescribed if fundal massage and bladder emptying do not resolve the atony.
Clinical Reasoning
Uterine atony is the most common cause of postpartum hemorrhage. The displaced, boggy fundus indicates poor contraction and likely bladder distention. Immediate mechanical intervention is the priority to control the source of bleeding before irreversible shock develops. Delegating notification while providing direct care follows the principle of prioritizing interventions that directly address the physiological cause.
Uterine Atony — Loss of muscle tone in the uterus, preventing it from contracting and compressing blood vessels at the placental site, which is the leading cause of postpartum hemorrhage.
Fundal Massage — A technique of massaging the uterine fundus through the abdomen to stimulate contraction, expel clots, and control bleeding in uterine atony.
Boggy Uterus — A uterus that feels soft and spongy upon palpation instead of firm and contracted, indicating poor muscle tone and risk of hemorrhage.