A nurse is caring for a client who experienced a complete uterine inversion immediately after delivery of the placenta. What is the nurse's highest priority action?

Manual replacement (Johnson maneuver) is the priority to restore uterine anatomy and control bleeding. Fluid resuscitation is important but secondary to addressing the root cause of hemorrhage.

Understanding the Emergency: Uterine Inversion
The clinical picture described—a non-palpable uterine fundus, a bluish mass at the vaginal introitus, severe hemorrhage, and profound hypotension with tachycardia—is the classic presentation of a complete uterine inversion. This is a rare, life-threatening obstetric emergency where the uterine fundus collapses into the endometrial cavity and protrudes through the cervix. The immediate, irreversible threat is hemorrhagic shock, but the trigger for the hemorrhage is the mechanical displacement and stretching of the uterus, which traps the organ and prevents it from contracting effectively. Therefore, the highest priority action targets the root cause: the inverted position of the uterus itself.

Why Manual Replacement is the Highest Priority
The correct answer is to attempt manual replacement of the inverted uterus back to its normal position. This is not simply one of several steps; it is the definitive, time-critical intervention that must occur as quickly as possible. The rationale is based on a clear pathophysiological cascade:

1. Mechanical Obstruction and Tissue Strangulation: When the uterus inverts, the broad and uterosacral ligaments are stretched, and the uterine arteries are compressed and kinked. This venous congestion rapidly leads to edema of the inverted fundus, making the tissue appear as the "large, round, bluish mass" noted in the scenario. As edema worsens, the cervical ring constricts the trapped tissue, further impeding blood flow and causing ischemia, which is the source of the client's severe pelvic pain [1, 2].
2. Refractory Hemorrhage and Neurogenic Shock: The inversion prevents the uterus from contracting, leading to massive postpartum hemorrhage from the atonic, engorged tissue. More critically, the stretching of the peritoneum and pelvic ligaments triggers a vagal response, causing profound neurogenic shock. This explains why the client's vital signs—BP 85/45 mmHg and HR 130 bpm—are disproportionately severe and do not initially respond to fluid resuscitation alone [2, 3].
3. The "Time is Tissue" Principle: The Johnson method of manual reduction is the first-line, life-saving maneuver [2, 3]. The goal is to push the fundus back through the cervix and restore normal anatomical position. This action immediately relieves the traction on the ligaments and peritoneum, breaking the vagal stimulation. It also decompresses the strangulated tissue, allowing the uterus to contract and control the hemorrhage. Delaying this step to start an IV or administer medications allows the cervical constriction ring to tighten and edema to worsen, making subsequent reduction attempts more difficult and increasing the risk of failure, which would then necessitate a surgical approach [1, 4].

Analysis of Other Options in the Context of Priority
- Option 1 (Establish IV access and fluid resuscitation): This is a critical and concurrent action, but it is not the highest priority. Resuscitation is a supportive measure that will fail if the underlying cause (the inversion) is not corrected. The hemorrhage and neurogenic shock are driven by the mechanical displacement; without manual reduction, fluid will continue to be lost and the vagal stimulus will persist, making stabilization impossible .
- Option 3 (Administer uterotonics): This is contraindicated before the uterus is repositioned. Administering an agent like oxytocin while the uterus is inverted would cause the cervical ring to contract and clamp down even more tightly on the trapped fundus, making manual reduction significantly harder or impossible [1, 4]. Uterotonics are given after successful reduction to promote contraction and prevent recurrence.
- Option 4 (Prepare for cesarean section): A cesarean section is an abdominal surgical procedure for delivering a fetus. It is not the treatment for a uterine inversion that occurs after a vaginal delivery. If manual reduction fails, the surgical intervention would be a laparotomy to perform a Huntington or Haultain procedure, not a cesarean section. This option represents a fundamental misunderstanding of the surgical management of this emergency .

The rapid clinical recognition of the bluish mass and absent fundus, as visually documented in case reports, is the trigger for immediate action [1, 3]. The nurse's highest priority is to initiate the manual reduction technique without delay, understanding that this single action addresses the root cause of the hemorrhage, pain, and shock simultaneously.