A nurse is assessing a client who is 72 hours postpartum following a cesarean delivery. Which assessment finding would be the priority concern requiring immediate intervention?
1Lochia rubra with clots larger than a quarter and soaking one pad per hour✓ 정답
2Breast engorgement with mild tenderness and warmth
3Episiotomy site with slight edema and minimal discomfort
4Uterine fundus palpated at the level of the umbilicus and firm
해설
Lochia rubra with large clots and soaking one pad per hour indicates postpartum hemorrhage, a medical emergency requiring immediate intervention. Other findings are normal postpartum variations.
Core Nursing ExplanationKey Concept Analysis: This question assesses the nurse's ability to recognize signs of a life-threatening postpartum complication and prioritize care. The core theme is identifying Postpartum Hemorrhage (PPH), a leading cause of maternal mortality. Normal postpartum findings must be distinguished from abnormal, dangerous signs. The priority is always the patient's Key Point!ABCs (Airway, Breathing, Circulation), and excessive bleeding directly threatens circulation.
Answer Rationale: The correct answer is ① because it describes classic signs of Postpartum hemorrhage. Key Point! The criteria for concerning lochia are: soaking one peripad per hour and clots larger than a quarter (or golf ball-sized). Lochia rubra (red discharge) is normal for the first 3-4 days, but the amount described indicates active, significant bleeding that can rapidly lead to hypovolemic shock. This requires immediate intervention such as uterine massage, notifying the provider, administering ordered uterotonic medications (e.g., Oxytocin), and preparing for possible surgical intervention.
Distractor Analysis:
Watch out for confusion! Option ②: Breast engorgement with mild tenderness and warmth is a normal physiologic response to milk production around days 3-5 postpartum. It is uncomfortable but not an emergency. Nursing care includes supportive measures like warm compresses, supportive bras, and frequent feeding/pumping.
Option ③: An Episiotomy site with slight edema and minimal discomfort is an expected finding in the early postpartum period. The nurse should monitor for signs of infection (e.g., increased redness, purulent drainage, foul odor, fever) but this finding itself is not a priority.
Option ④: A uterine fundus palpated at the level of the umbilicus and firm is a normal and desired finding at 72 hours postpartum. A firm fundus indicates the uterus is contracting well to control bleeding at the placental site. A boggy (soft) fundus that is above the umbilicus would be a concern for uterine atony and hemorrhage.
Related Concepts: Postpartum assessment is guided by the BUBBLE-HE mnemonic (Breasts, Uterus, Bladder, Bowels, Lochia, Episiotomy/Hemorrhoids, Emotional status). Understanding normal vs. abnormal progression for each component is critical. The "Four T's" mnemonic for causes of PPH (Tone, Trauma, Tissue, Thrombin) helps guide interventions.
Nursing Clinical Practice GuideClinical Scenario: You are the nurse on the postpartum unit. Your patient, Ms. Jones, is 3 days post-cesarean section. During your routine assessment, you note her peripad is completely saturated with bright red blood and contains several large, quarter-sized clots. She reports changing pads every hour. Her skin is pale and cool, and she feels lightheaded.
Nursing Intervention Strategy:
1Immediate Assessment & Action (ABCs)- Call for help. Stay with the patient.
- Assess vital signs: Tachycardia and hypotension are late signs of shock. A rising pulse is an early sign.
- Perform bimanual uterine massage: Place one hand on the abdomen at the fundus and the other inside the vagina, compressing the uterus between them to stimulate contractions.
- Check the fundus: Is it boggy? Massage until firm.
2Notify the Provider & Prepare Interventions- Report findings immediately: "Client is 72 hours postpartum, saturating pads hourly with large clots, fundus initially boggy."
- Administer ordered uterotonic medications (e.g., IV Oxytocin, IM Methylergonovine, IM Carboprost). Know contraindications (e.g., Methylergonovine is contraindicated in hypertension).
- Increase IV fluids (likely Lactated Ringer's) to support circulation.
- Prepare for possible transfer to OR or procedures like a D&C (Dilation and Curettage).
3Ongoing Monitoring & Support- Continue to monitor lochia, fundal height/firmness, and vital signs every 15 minutes or more frequently.
- Provide emotional support to the patient and family, explaining interventions calmly.
Patient Safety and Precautions:
- Never delegate fundal massage or the assessment of a patient with active PPH to unlicensed personnel.
- Be aware that a firm fundus does not always rule out hemorrhage (e.g., from a cervical or vaginal laceration).
- Monitor for signs of coagulopathy (oozing from IV sites, petechiae).
1Bimanual Uterine MassageExplain the procedure to the patient. Use clean gloves. Maintain firm, circular pressure until the uterus contracts and feels hard like a grapefruit. Over-massage can cause fatigue; massage only as needed to maintain tone.
2Oxytocin (Pitocin) AdministrationOften the first-line drug. Given IV infusion (e.g., 10-40 units in 1L IV fluid) or IM. Monitor for water intoxication (headache, nausea, confusion) with prolonged high-dose IV infusion.
3Methylergonovine (Methergine)Given IM (0.2 mg). Key Point! Contraindicated in patients with hypertension as it causes vasoconstriction. Monitor blood pressure before and after administration.
4Carboprost (Hemabate)Given IM (250 mcg). Can cause diarrhea, fever, chills. Contraindicated in asthma.
A Word from Your Senior Nurse
"In postpartum nursing, your hands and your eyes are your best assessment tools. Feeling that fundus become firm under your hand after a good massage is one of the most satisfying feelings because you know you've just stopped a hemorrhage. Remember, a patient can look 'fine' one minute and be in serious trouble the next. Always quantify bleeding—'soaking one pad per hour' is objective and actionable. On the NCLEX, they love to test your ability to sift through normal postpartum discomforts to find the one finding that screams 'DANGER.' Think: What can kill my patient first? Bleeding always tops that list."
Postpartum Hemorrhage — Excessive bleeding (≥500 mL for vaginal, ≥1000 mL for cesarean) after childbirth. A leading cause of maternal mortality. The "Four T's" are common causes: Tone (uterine atony), Trauma (lacerations), Tissue (retained placenta), Thrombin (coagulopathy).
Lochia — Postpartum vaginal discharge. Lochia rubra (red, days 1-3), lochia serosa (pink/brown, days 4-10), lochia alba (yellow/white, up to 6 weeks). Abnormal: soaking >1 pad/hour, foul odor, large clots.
Uterine Atony — The most common cause of PPH. Failure of the uterine muscle to contract adequately after delivery, leading to bleeding from the placental site. Risk factors include overdistended uterus, prolonged labor, and multiparity.
Fundal Assessment — Palpation of the uterine fundus to assess height (fingerbreadths above/below umbilicus) and tone (firm vs. boggy). After delivery, the fundus is at the umbilicus and should descend about 1 fingerbreadth per day.
BUBBLE-HE Assessment — A comprehensive postpartum assessment mnemonic: Breasts, Uterus, Bladder, Bowels, Lochia, Episiotomy/Hemorrhoids, Emotional status (H=Homans' sign for DVT, E=Education). A systematic framework for nursing care.
Concept Summary
Concept
Normal Postpartum Finding (72 hrs)
Abnormal Finding (Requiring Action)
Lochia
Lochia rubra, moderate flow (changing pad every 2-3 hrs), small clots