A postpartum client delivered vaginally 1 hour ago and is experiencing heavy bleeding. Her vital signs are: BP 90/50 mmHg, HR 120 bpm, RR 24/min, temperature 98.6°F. The fundus is boggy and located 2 cm above the umbilicus. What is the priority nursing intervention?
A 28-year-old woman delivered her second baby vaginally 2 hours ago after a prolonged labor of 18 hours. She is experiencing continuous heavy bleeding with clots larger than a quarter. Her vital signs show hypotension and tachycardia, and she appears pale and anxious.
1Administer oxygen via nasal cannula at 2-4 L/min
2Insert a large-bore IV catheter and initiate fluid resuscitation
3Notify the healthcare provider immediately about the bleeding
4Perform fundal massage to stimulate uterine contraction✓ 정답
해설
Fundal massage is the priority to stimulate uterine contraction for a boggy fundus in postpartum hemorrhage. Other interventions (oxygen, IV fluids, notification) are important but follow after controlling bleeding.
Core Nursing ExplanationKey Concept Analysis: This question tests the priority nursing intervention for a patient with Postpartum hemorrhage (PPH) due to Uterine atony. The key findings are heavy bleeding with clots, a boggy (soft, non-contracted) fundus located above the umbilicus, and signs of hypovolemic shock (hypotension BP 90/50 mmHg, tachycardia HR 120 bpm). The primary pathophysiological problem is the uterus's inability to contract effectively, which is the most common cause of early PPH. The immediate goal is to stop the bleeding at its source.
Answer Rationale: Key Point! The priority is Perform fundal massage to stimulate uterine contraction. This is a direct, hands-on intervention the nurse can initiate immediately to address the root cause (uterine atony). A firm, contracted uterus compresses the spiral arteries at the placental site, which is the primary mechanism for controlling bleeding after delivery. All other vital actions (oxygen, IV access, notifying the provider) are critically important but are supportive measures that follow or occur concurrently with the primary action of controlling the hemorrhage.
Distractor Analysis:
Watch out for confusion! While B: Insert a large-bore IV catheter and initiate fluid resuscitation is an urgent and essential action for hypovolemia, it treats the consequence (blood loss) rather than the cause (bleeding). You must stop the bleeding first; otherwise, you are just "putting fluid in while blood pours out."
Watch out for confusion!A: Administer oxygen via nasal cannula supports oxygenation but is a secondary intervention for a patient in shock. The primary problem is volume loss, not primarily respiratory.
Watch out for confusion!C: Notify the healthcare provider immediately is absolutely necessary, but the nurse's independent, immediate action to control the bleeding cannot wait. The nurse acts first with fundal massage while someone else notifies the provider or concurrently.
Related Concepts: This scenario illustrates the "4 T's" mnemonic for causes of PPH: Tone (uterine atony), Trauma (laceration), Tissue (retained placenta), and Thrombin (coagulopathy). The boggy fundus points directly to "Tone." Nursing management follows the ABC (Airway, Breathing, Circulation) principle, but in obstetric emergencies, controlling the source of bleeding (the uterus) is often the first critical "C" (Circulation) intervention.
Concept Summary
Concept
Description
Clinical Significance
Postpartum Hemorrhage (PPH)
Blood loss >500 mL after vaginal delivery or >1000 mL after C-section.
Leading cause of maternal mortality. Early PPH occurs within first 24 hours.
Uterine Atony
Failure of the uterine muscle to contract after delivery.
Most common cause of PPH (70-80%). Risk factors: prolonged labor, overdistended uterus, multiparity.
Boggy Fundus
Uterus feels soft, spongy, and poorly contracted on palpation.
Key assessment finding for uterine atony. A firm, contracted fundus should be at or below the umbilicus.
Fundal Massage
Bimanual compression of the uterine fundus to stimulate contraction.
First-line, independent nursing intervention for a boggy fundus and PPH.
Side-by-Side Comparison!
Intervention
Priority & Rationale
When to Use
Fundal Massage
Key Point! FIRST. Treats the root cause (atony) by stimulating contraction.
Immediately upon finding a boggy fundus with bleeding.
Establish IV Access / Fluids
SECOND (or concurrent). Treats hypovolemia and supports circulation.
As soon as possible after or while initiating fundal massage.
Notify Provider
ESSENTIAL but not the *first* hands-on action. Enables order for medications (e.g., Oxytocin).
Concurrently, often delegated while nurse performs massage.
Administer Oxygen
SUPPORTIVE. Increases O2 delivery to compromised tissues.
After or with initial interventions, especially if signs of shock.
Anatomy, Physiology & Pharmacology Points
Physiology: After placental separation, the myometrial fibers contract, shortening and kinking the spiral arteries that supplied the placenta. This is the primary hemostatic mechanism. Uterine atony prevents this, leading to unchecked bleeding.
Anatomy: A fundus above the umbilicus (2 cm above in this case) immediately postpartum suggests uterine distention with blood/clots, confirming inadequate contraction.
Pharmacology: After fundal massage, the provider will typically order uterotonic medications: Oxytocin (Pitocin) (first-line IV), Methylergonovine (Methergine), Carboprost (Hemabate), or Misoprostol (Cytotec).
Memory Tips
Mnemonic: "Massage First, Fluids Fast" for PPH due to atony.
Think: "Stop the faucet before mopping the floor." Fundal massage stops the bleeding (faucet), IV fluids replace volume (mop).
Fundus Check Rule: A firm fundus = good. A boggy fundus = act NOW with massage.
High-Frequency NCLEX Topics
The NCLEX loves testing priority-setting in obstetric emergencies. PPH is a classic scenario. Remember: Your independent nursing action that directly addresses the etiology (like fundal massage for atony) is almost always the first priority over notifying, documenting, or even starting supportive care.
Watch Out for Question Variations!
If the fundus is firm and midline but bleeding is heavy, the cause is likely Trauma (laceration) or Tissue (retained placenta). The priority then shifts to inspection for lacerations/notifying the provider for manual removal of placenta.
The question might ask for the next intervention after fundal massage (Answer: typically, administer ordered uterotonic medication like Oxytocin).
It could combine PPH with coagulopathy (Thrombin), asking for priority lab tests (e.g., coagulation studies like fibrinogen).
Nursing Clinical Practice GuideClinical Scenario: You are the nurse on the postpartum unit. One hour after a vaginal delivery, your patient calls you, stating she is bleeding heavily. You find large clots in the peripad, the patient is pale and anxious, her skin is cool and clammy, and her vital signs are declining.
Nursing Intervention Strategy:
Immediate Action (First 30 seconds): Call for help (activate emergency bell, ask family to get another nurse). With one hand on the abdomen, locate the fundus. If it is boggy, immediately begin firm, circular bimanual fundal massage. Place one hand on the abdomen at the fundus and the other in the vagina, compressing the uterus between them for severe cases.
Concurrent Actions (Next 1-2 minutes): While massaging, have your assisting colleague:
Apply oxygen via non-rebreather mask at 10-15 L/min (not nasal cannula) for significant shock.
Establish two large-bore (16- or 18-gauge) IV lines and begin rapid infusion of isotonic crystalloid (Normal Saline or Lactated Ringer's).
Notify the obstetric provider, charge nurse, and alert the blood bank.
Ongoing Management & Evaluation:
Continue massage until the fundus is firm. Administer uterotonic medications as ordered (Oxytocin IV is typical first-line).
Monitor vital signs every 5-15 minutes. Quantify blood loss by weighing pads/chux.
Prepare for possible interventions: Bakri balloon tamponade, transfer to OR, or blood transfusion.
Provide emotional support and clear explanations to the patient and family.
Patient Safety and Precautions:
Fundal Massage Technique: Do not over-massage once the uterus is firm, as this can cause fatigue and re-bleeding. Support the lower uterine segment during massage to prevent uterine inversion (a rare but serious complication).
Medication Caution: Oxytocin can cause water intoxication with high doses/long use. Methylergonovine (Methergine) is contraindicated in hypertension. Carboprost (Hemabate) can cause bronchospasm and is contraindicated in asthmatics.
Monitoring: Continuously assess for signs of worsening shock: decreasing level of consciousness, increasing tachycardia, dropping blood pressure, and decreasing urine output (should be >30 mL/hr).
Nursing Procedure & Medication FlowProcedure: Bimanual Fundal Massage
1. Explain the procedure to the patient.
2. Ensure bladder is empty (catheterize if needed).
3. Don gloves. Place one hand (usually the dominant) on the abdomen just above the symphysis pubis to support the uterus.
4. Place the other hand on the fundus. Apply firm, downward pressure in a circular motion.
5. Continue until the uterus contracts firmly. Express any clots that accumulate.
Medication: Oxytocin (Pitocin) for PPH
- Route/Dose: Typically 10-40 units in 500-1000 mL IV fluid (e.g., Normal Saline) infused rapidly.
- Action: Stimulates powerful uterine contractions.
- Nursing Priority: Monitor for excessive fluid intake (I&O) and watch for signs of water intoxication (headache, confusion, seizures).
A Word from Your Senior Nurse
"In the controlled chaos of a postpartum hemorrhage, your hands are the first and most powerful tool. That fundal massage isn't just a skill; it's a life-saving intervention. On the NCLEX and in real life, they're testing your ability to think like a nurse: see the problem (boggy uterus), know the immediate fix (massage), and then mobilize the team. Never underestimate the power of a firm, knowledgeable touch. Stay calm, act decisively, and always remember you are that patient's advocate and first responder."