A 28-year-old primigravida delivered a 3,800-gram infant vaginally 2 hours ago after a prolonged labor and is experiencing heavy bleeding. Which nursing action should be the FIRST priority?
1Administer prescribed oxytocin infusion
2Insert a large-bore IV catheter
3Assess fundal height and perform fundal massage✓ 정답
4Prepare for emergency blood transfusion
해설
In postpartum hemorrhage, immediate assessment and fundal massage stimulate uterine contraction to control bleeding from atony. Other actions (oxytocin, IV access, transfusion) are important but secondary after initial assessment and massage.
Core Nursing Explanation
This question tests the priority nursing action for a patient with suspected Postpartum Hemorrhage (PPH). The patient is a primigravida with risk factors (prolonged labor, large infant), presenting with heavy bleeding 2 hours postpartum.
Key Concept Analysis
The core theme is the Key Point!ABCs of emergency care applied to obstetric bleeding. While Airway, Breathing, and Circulation are always primary, in postpartum hemorrhage, the "C" (Circulation) is directly threatened by Uterine Atony (the most common cause of early PPH). The priority is to identify and treat the source of bleeding immediately. The uterus is a large, vascular organ, and bleeding from the placental site can be life-threatening rapidly.
Answer RationaleKey Point! The FIRST priority is Assess fundal height and perform fundal massage. This action serves a dual purpose: Assessment and Intervention.
1. Assessment: Checking the fundus determines if it is Boggy (soft, not well-contracted), which confirms uterine atony. A firm, contracted fundus would point to other causes of bleeding (e.g., lacerations, retained placental fragments).
2. Intervention: Fundal massage is a direct, non-pharmacological method to stimulate the uterine muscle to contract, which clamps down on the open blood vessels at the placental site and stops the bleeding. This can be initiated instantly by the nurse while calling for help and before administering medications.
Distractor AnalysisWatch out for confusion! All other actions are crucial but are not the first priority.
• Option ① (Administer oxytocin): Oxytocin is the first-line medication for uterine atony. However, the nurse must first assess the fundus to confirm atony is the cause. Massage can be started immediately while the medication is being prepared.
• Option ② (Insert large-bore IV): Establishing IV access is vital for fluid resuscitation and medication administration. However, if the uterus remains atonic, the patient will continue to bleed despite fluids. The immediate action is to stop the bleeding at its source.
• Option ④ (Prepare for transfusion): This is a critical intervention for significant blood loss, but it is a supportive measure, not a treatment for the cause. The primary goal is to stop the bleeding to prevent the need for further transfusion.
Related Concepts
This scenario highlights the "4 Ts" mnemonic for causes of PPH: Tone (uterine atony), Trauma (lacerations), Tissue (retained placenta), and Thrombin (coagulopathy). Fundal assessment addresses "Tone" first, as it is the most common. Nursing management follows the sequence: Massage → Medicate (uterotonics like oxytocin, methylergonovine, carboprost) → Manually explore/repair (if needed).
Concept Summary
• Postpartum Hemorrhage (PPH): Blood loss >500 mL after vaginal birth or >1000 mL after cesarean.
• Uterine Atony: Failure of the uterus to contract adequately after delivery; the #1 cause of early PPH.
• Fundal Massage: First-line, immediate nursing intervention for a boggy uterus.
• Nursing Priority: Always assess (find the cause) before intervening when the patient is stable enough for a quick assessment. In hemorrhage, assess the fundus first.
Side-by-Side Comparison!
Intervention
Purpose
Priority Sequence
Fundal Assessment & Massage
Diagnose & treat uterine atony immediately.
FIRST - Do this while calling for help.
Administer Uterotonics (Oxytocin)
Pharmacologically induce uterine contraction.
Second - Initiate after/during massage.
Establish Large-Bore IV Access
Provide route for fluids, blood, medications.
Concurrent/Immediately after - Often done by a second nurse.
Prepare for Blood Transfusion
Replace lost volume and clotting factors.
Later - Based on ongoing assessment and lab values (Hgb/Hct).
Anatomy, Physiology & Pharmacology Points
• Physiology: After placental separation, the uterus contracts to constrict the spiral arteries that supplied the placenta. This is the primary mechanism for hemostasis.
• Pharmacology - Oxytocin: Acts on uterine myometrium to stimulate rhythmic contractions. Given IV infusion or IM. Side effect: water intoxication (due to ADH-like effect).
• Pharmacology - Methylergonovine: Causes sustained tetanic uterine contraction. Contraindicated in hypertension. Given IM.
Memory Tips
• M.A.M.A. for PPH priority: Massage → Assess (vitals, fundus) → Medicate → Access (IV).
• Think: "Stop the bleeding FIRST, then support the system." The fundus is the "tap." Turn it off (massage/contract) before you try to refill the bucket (IV fluids/transfusion).
High-Frequency NCLEX Topics
Postpartum hemorrhage is a classic High Yield OB emergency. The NCLEX loves to test:
1. Identifying risk factors (prolonged labor, overdistended uterus, multiparity).
2. Prioritizing actions (massage/assessment first).
3. Knowing medication indications and contraindications (e.g., don't give methylergonovine to a hypertensive patient).
Watch Out for Question Variations!
• If the question adds: "The fundus is firm and midline, but bleeding is heavy," the priority shifts to inspecting for Trauma (lacerations of cervix/vagina).
• If the patient is hypotensive and tachycardic (in shock), the priority actions might include calling a code, initiating Two large-bore IVs, and administering oxygen concurrently with fundal massage, as the patient's systemic circulation is now the immediate threat.
Nursing Clinical Practice GuideClinical Scenario
You are the nurse on the postpartum unit. Your patient, Anna, who had a long labor and delivered a large baby, calls you to her room. She says, "I feel like I'm bleeding a lot." You see saturated perineal pads and blood on the bed linens.
Nursing Intervention Strategy
1Immediate Action (First 60 seconds)Don gloves. Ask a colleague to call the provider/rapid response. Assess the fundus—it is boggy and deviated to the right. You immediately begin bimanual fundal massage: one hand on the abdomen over the fundus, the other inside the vagina supporting the uterus, applying firm, circular pressure. You note clots being expelled.
2Concurrent Actions (Team-Based)While you massage, your colleague establishes an 18-gauge IV and starts a bolus of Lactated Ringer's. You instruct them to draw labs (CBC, coagulation panel, type and crossmatch) and prepare the prescribed oxytocin IV infusion.
3Ongoing Assessment & CareContinue massage until the fundus is firm. Administer oxytocin. Monitor vital signs every 5-15 minutes. Quantify blood loss by weighing pads/chux. Assess for signs of shock (tachycardia, hypotension, pallor, anxiety).
4Patient Education & SupportExplain all actions to Anna calmly. "I'm massaging your uterus to help it contract and stop the bleeding. This pressure might be uncomfortable." Provide emotional support; this is a frightening experience.
Patient Safety and Precautions
• Fundal Massage Technique: Do not over-massage once the uterus is firm, as this can cause fatigue and lead to re-bleeding.
• Medication Safety: Double-check the oxytocin drip rate. Run it via an infusion pump. Monitor for water intoxication symptoms (headache, nausea, confusion).
• Infection Control: Maintain strict aseptic technique during any vaginal examination or procedure.
Nursing Procedure & Medication FlowProcedure: Bimanual Fundal Massage
1. Explain the procedure to the patient.
2. Ensure privacy, position patient supine.
3. Don clean gloves.
4. Place one hand (usually the dominant) on the abdomen just above the symphysis pubis, cupping the uterine fundus.
5. Place the other hand in the vagina, forming a fist, and press against the anterior wall of the uterus.
6. Apply firm, steady pressure with the abdominal hand, massaging the fundus in a circular motion while the vaginal hand provides counter-support.
7. Continue until the uterus becomes firm and bleeding diminishes.
Medication: Oxytocin (Pitocin) IV Infusion
• Common Order: 10-40 units in 1000 mL IV fluid (e.g., Lactated Ringer's).
• Administration: Start infusion per protocol (e.g., 10-20 milliunits/min), titrate to control bleeding and maintain uterine tone.
• Key Monitoring: Uterine firmness, vaginal bleeding, vital signs, and fluid intake/output (I&O) for signs of fluid overload.
A Word from Your Senior Nurse
"In postpartum, your hands are your first and most important assessment tool. Feeling that boggy fundus is a critical finding that triggers immediate life-saving action. Never underestimate the power of a good fundal massage—it's simple, requires no equipment, and can literally stop a hemorrhage in its tracks. On the NCLEX and in real life, remember: assess the cause of the problem before you jump to treatments. In this case, your assessment (feeling the fundus) IS the first step of your intervention (massaging it). Stay calm, act quickly, and work as a team. You've got this!"
Postpartum Hemorrhage — Excessive bleeding after childbirth, defined as blood loss >500 mL after vaginal delivery or >1000 mL after cesarean section. It is a leading cause of maternal mortality.
Uterine Atony — The failure of the uterus to contract adequately after delivery of the placenta. It is the most common cause of early postpartum hemorrhage.
Fundal Massage — A manual technique where the nurse applies external pressure to the uterine fundus to stimulate contraction and control bleeding from atony. It is the first-line nursing intervention for a boggy uterus.
Oxytocin — A hormone and medication that stimulates uterine contractions. It is the first-line pharmacologic agent used to prevent and treat postpartum hemorrhage due to uterine atony.
Primigravida — A woman who is pregnant for the first time. In this context, it is a risk factor for prolonged labor, which is a risk factor for uterine atony and postpartum hemorrhage.