A nurse is caring for a 28-year-old postpartum client who delivered vaginally 3 weeks ago. She reports continued heavy bleeding with clots. Examination reveals a soft, boggy uterus larger than expected. Vital signs: temperature 99.2°F (37.3°C), pulse 88 bpm, respirations 18/min, blood pressure 110/70 mmHg. Hemoglobin is 9.8 g/dL. The healthcare provider diagnoses subinvolution of the uterus. Which nursing intervention should be the priority?

Subinvolution with heavy bleeding and boggy uterus requires uterotonic medications to stimulate contractions, control hemorrhage, and promote involution. Other options (iron supplements, fluid intake, emotional support) address anemia or support but are not priority.

Core Nursing Explanation Key Concept Analysis: This question assesses the priority nursing intervention for a patient diagnosed with Subinvolution of the uterus. Subinvolution is the failure of the uterus to return to its non-pregnant size and state after delivery. The key pathophysiological problem is that the uterine muscle is not contracting effectively (Uterine atony), leading to a soft, boggy fundus, continued heavy bleeding, and retained placental fragments or clots. This prevents the normal process of hemostasis via compression of the spiral arteries at the placental site.

Answer Rationale: Key Point! The priority is to address the underlying cause of the bleeding. The patient's soft, boggy, enlarged uterus indicates poor uterine tone. The primary treatment for this is the administration of Uterotonic medications (e.g., Methylergonovine, Oxytocin, Carboprost). These drugs stimulate strong, sustained uterine contractions, which will compress the blood vessels at the placental site to stop the bleeding, expel any retained clots or tissue, and promote the normal involution process. This directly addresses the life-threatening risk of postpartum hemorrhage, even though her current vital signs are stable.

Distractor Analysis:

• Option 1 (Administer iron supplements): While the patient has anemia (Hb 9.8 g/dL vs. normal 12-15 g/dL), this is a consequence of the ongoing blood loss. Treating the anemia is important for long-term recovery but does not stop the active bleeding. It is a supportive, not a priority, intervention.
• Option 2 (Encourage increased fluid intake): Hydration is generally important, but the patient is not showing signs of hypovolemic shock (vital signs are stable). This intervention does not address the primary problem of uterine atony and hemorrhage.
• Option 3 (Administer uterotonic medications): This is the correct answer. It directly treats the cause of subinvolution and hemorrhage.
• Option 4 (Provide emotional support): This is always a component of holistic nursing care, especially for a worried new mother. However, in the nursing process, physiological stability (stopping the bleeding) takes precedence over psychosocial needs when there is an active threat.

Related Concepts: This scenario illustrates the application of Maslow's Hierarchy of Needs and ABC (Airway, Breathing, Circulation) priorities in nursing. The ongoing bleeding is a threat to circulation, making physiological interventions the priority. It also connects to the pathophysiology of the normal postpartum period (Involution) and its complications.

Concept Summary

Concept	Description	Clinical Significance
Subinvolution	Failure of the uterus to return to its pre-pregnant size and condition postpartum.	Causes prolonged lochia, heavy bleeding, boggy uterus. Risk for late postpartum hemorrhage.
Uterine Atony	Lack of uterine muscle tone, preventing contraction and compression of blood vessels.	The most common cause of postpartum hemorrhage, both early and late.
Uterotonic Medications	Drugs that stimulate uterine contractions (e.g., Oxytocin, Methylergonovine, Carboprost).	First-line treatment for atony and subinvolution to control bleeding and promote involution.
Postpartum Hemorrhage (PPH)	Blood loss >500 mL after vaginal delivery or >1000 mL after C-section. Can be early ( 임상 시나리오 Nursing Clinical Practice Guide Clinical Scenario: You are a nurse in a postpartum clinic. Ms. Johnson, 28, presents 3 weeks after a vaginal delivery. She is anxious, stating, "The bleeding was supposed to be done by now, but I'm still filling pads and passing big clots." Your assessment confirms a soft, boggy uterus palpable above the symphysis pubis. The provider diagnoses subinvolution and prescribes methylergonovine 0.2 mg orally every 6 hours for 48 hours. Nursing Intervention Strategy: Assessment: Perform a focused assessment: vital signs, fundal height/firmness, amount and character of lochia (saturating a pad in 1 pad per hour, passing clots larger than a golf ball, dizziness, lightheadedness, or shortness of breath. Infection Prevention: Subinvolution can be caused by endometritis. Monitor temperature and for foul-smelling lochia. Teach perineal hygiene (wipe front to back, change pads frequently). Nursing Procedure & Medication Flow Administering Uterotonic Medications for Subinvolution: Verify Order & Patient: Confirm the medication, dose, route, and frequency. Perform two-patient identifiers. Pre-Assessment: Assess and document baseline vital signs, especially BP. Assess uterine firmness and lochia. Administration: Oral (Methylergonovine): Administer with a full glass of water. May give with food if nausea occurs. IM (Methylergonovine or Carboprost): Use Z-track technique for Carboprost to minimize tissue irritation. Post-Administration: Monitor for therapeutic effect (firm uterus, decreased bleeding) and adverse effects every 15-30 minutes initially. Reassess vital signs per protocol. Documentation: Document medication given, pre/post vital signs, uterine assessment findings, client response, and any education provided. A Word from Your Senior Nurse "Postpartum bleeding is one of those things we never take lightly. A uterus that stays boggy is like a faucet that won't turn off. Your quick action to administer that uterotonic isn't just following an order—it's actively stopping a hemorrhage before it becomes an emergency. In clinical practice, you'll learn to trust your assessment: if it feels soft and big when it should be firm and small, act. This NCLEX question is testing that exact clinical judgment: see the problem (boggy uterus + bleeding), know the fix (contract it with meds), and prioritize it above all else. That's the kind of thinking that saves lives on the floor." 핵심 개념 Subinvolution of the Uterus — Failure of the uterus to return to its non-pregnant size and tone after childbirth, often leading to prolonged or heavy bleeding (lochia). Uterine Atony — Lack of tone in the uterine muscle after delivery, preventing contraction and compression of blood vessels at the placental site; the most common cause of postpartum hemorrhage. Uterotonic Medications — Drugs that stimulate contractions of the uterine muscle (e.g., Oxytocin, Methylergonovine). Used to treat or prevent uterine atony and control postpartum bleeding. Postpartum Hemorrhage — Significant blood loss after childbirth, defined as >500 mL after vaginal delivery or >1000 mL after cesarean section. Can be early ( Fundal Massage — A manual nursing technique where one hand is placed just above the symphysis pubis to support the uterus while the other hand massages the uterine fundus in a circular motion. Used to stimulate contraction and control bleeding. 마이메르시로 국가고시 완벽 대비 기출문제와 상세 해설을 무료로. 내 약점을 분석하고 진도를 관리하며 더 똑똑하게 공부하세요. 무료로 시작하기 App Store Google Play 학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요.