A postpartum client delivered vaginally 4 hours ago and is experiencing heavy vaginal bleeding. The nurse assesses a boggy, soft uterus that is displaced above the umbilicus. What is the priority nursing intervention?
1Administer methylergonovine (Methergine) as ordered
2Perform fundal massage and assist the client to void✓ 정답
3Increase the oxytocin infusion rate immediately
4Prepare the client for emergency surgery
해설
Fundal massage and assisting to void are priority for uterine atony with suspected bladder distention, as they directly address uterine contraction and relieve mechanical obstruction. Other interventions are secondary.
Clinical Judgment
This question assesses prioritization and immediate non-pharmacological interventions for uterine atony. The key clue is "boggy, soft uterus displaced above the umbilicus". This indicates a non-contracted, soft uterus that has been pushed upward due to bladder distention. A full bladder is a correctable cause that physically impedes uterine contraction. Therefore, the top priority interventions are fundal massage to stimulate contraction and assisting with voiding to relieve bladder pressure. These are basic yet effective first-line measures that should be attempted before administering medications or preparing for surgery.
Memory Tip: Before Meds, Massage & Micturition! For uterine atony, think of massage and voiding before medications (Methergine, Oxy).
KR vs US
Both Korea and the US emphasize fundal massage as a first-line intervention, but the US NGN/CJMM places particular importance on a systematic approach that first addresses a 'reversible cause.' Bladder distention is one of the most common reversible causes.
임상 시나리오
Clinical Practice Guide
In managing postpartum hemorrhage (PPH), the fundal massage technique: Place one hand above the pubic symphysis to support the uterus, and place the other hand on the uterine fundus, applying gentle but firm circular pressure. Be careful, as excessive force can cause uterine inversion. After assisting with voiding, it is essential to reassess the uterine position and firmness.
Caution
In SATA (Select All That Apply) questions asking about "priority," non-pharmacological interventions are often the first priority. Also, a uterus that is "displaced above the umbilicus" is not simply an enlarged uterus; you must distinguish that it is displacement due to bladder distension.
핵심 개념
Uterine Atony — Uterine atony. After delivery, the uterus fails to contract adequately, making it the most common cause of postpartum hemorrhage.
Fundal Massage — Fundal massage. A non-pharmacological first-line intervention for uterine atony that stimulates uterine contraction and controls bleeding by massaging the uterine fundus.
Bladder Distention — Bladder distension. In the postpartum period, urinary retention can cause the bladder to fill and displace the uterus, which may interfere with contractions.
Postpartum Hemorrhage — Postpartum hemorrhage. Refers to bleeding of 500 mL or more within 24 hours after vaginal delivery, or 1000 mL or more after cesarean section.
Boggy Uterus — Soft uterus. A condition where the uterus does not contract firmly and feels soft and spongy, a typical sign of uterine atony.