# A nurse is assessing a postpartum client 24 hours after vaginal delivery. Which assessment finding would be the priority concern requiring immediate nursing intervention?

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> subject: Maternal Newborn Health

## 문제

A nurse is assessing a postpartum client 24 hours after vaginal delivery. Which assessment finding would be the priority concern requiring immediate nursing intervention?

## 보기

1. Lochia rubra with small clots and mild cramping during breastfeeding
2. Fundus located 3 cm above the umbilicus and displaced to the right side **✔ 정답**
3. Breast engorgement with mild tenderness in a breastfeeding mother
4. Perineal edema with intact sutures and no signs of infection

**정답: 2**

## 해설

A fundus 3 cm above the umbilicus and displaced to the right indicates uterine atony and bladder distention, which are priority concerns for postpartum hemorrhage requiring immediate intervention. Other findings are normal postpartum variations.

## 심화 해설

Clinical Reasoning & Priority Setting

The priority concern is a boggy uterus that is displaced, indicating a full bladder and uterine atony, which is the leading cause of postpartum hemorrhage (PPH).

Pathophysiology & Mechanism

After delivery, the uterine muscle must contract firmly to compress the open vessels at the placental site. When the bladder becomes distended, it mechanically pushes the uterus upward and laterally, preventing it from contracting effectively. This condition, known as uterine atony, leaves the spiral arteries and venous sinuses open, leading to rapid blood loss. A fundus palpated 3 cm above the umbilicus and deviated to the right is a classic sign of a distended bladder obstructing uterine involution. The physiological management of the third stage of labor, including immediate skin-to-skin contact and early breastfeeding, supports endogenous oxytocin release to maintain uterine tone and prevent atony [1]. However, if a mechanical barrier like a full bladder is present, these physiological protective mechanisms are overridden, and the risk of severe hemorrhage escalates critically.

Analysis of Assessment Findings

| Option | Assessment Finding | Clinical Interpretation |
| --- | --- | --- |
| 1 | Lochia rubra with small clots and mild cramping during breastfeeding | Expected finding. Breastfeeding releases exogenous oxytocin, causing physiologic afterpains and a transient increase in lochia flow. Small clots are normal in the first 24 hours. |
| 2 | Fundus 3 cm above the umbilicus and displaced to the right | Abnormal and urgent. Indicates a distended bladder causing uterine displacement and atony. This is the primary precursor to PPH if not immediately corrected by bladder emptying and fundal massage. |
| 3 | Breast engorgement with mild tenderness | Expected physiologic change as milk transitions from colostrum to mature milk around 24–72 hours postpartum. Managed with frequent feeding and cold compresses, not an emergency. |
| 4 | Perineal edema with intact sutures and no signs of infection | Expected finding following tissue trauma and repair. Ice packs and hygiene are appropriate nursing interventions, but this does not pose an immediate systemic threat. |

Immediate Nursing Intervention

The nurse must first assist the client to empty the bladder completely. If the client cannot void spontaneously, straight catheterization may be necessary. Immediately after bladder emptying, the nurse performs firm fundal massage to stimulate contraction. This sequence directly addresses the mechanical cause of the atony, restoring the physiological barrier against PPH. The literature emphasizes that active management of the third stage of labor and early postpartum period—including ensuring uterine contraction—is crucial for preventing PPH, as uterine atony accounts for the majority of primary PPH cases [1].References (research sources)

- [1]Literature Review: Physiological Management for Preventing Postpartum Hemorrhage.Research articleAlmutairi WM. (2021) · DOI: 10.3390/healthcare9060658

## 임상 시나리오

Clinical Practice Guide: Postpartum Fundal Assessment & Bladder Distension

**Scenario:** A nurse identifies a postpartum client's fundus as boggy, located 3 cm above the umbilicus, and displaced to the right. This is a clinical emergency requiring immediate action to prevent postpartum hemorrhage (PPH) due to uterine atony.

Immediate Nursing Interventions

- **Assist with Bladder Emptying:** The priority is to relieve the bladder distension mechanically obstructing uterine contraction. Assist the client to the bathroom or provide a bedpan. If unable to void, prepare for straight catheterization per order.

- **Reassess the Fundus:** Immediately after the bladder is emptied, re-palpate the fundus. It should be firm, midline, and at or below the umbilicus. If it remains boggy, initiate fundal massage.

- **Perform Fundal Massage:** Support the lower uterine segment with one hand and gently but firmly massage the fundus with the other in a circular motion until it becomes firm. Do not massage a firm uterus as this can cause unnecessary tissue trauma.

- **Monitor for Hemorrhage:** Assess lochia amount, color, and presence of clots. Weigh perineal pads (1 gram = 1 mL blood loss) for objective measurement. Monitor vital signs for signs of hypovolemia (tachycardia, hypotension).

- **Initiate Provider Notification:** Report findings of persistent atony, excessive bleeding, or inability to void. Anticipate orders for uterotonic medications (e.g., oxytocin, methylergonovine) and intravenous fluid resuscitation.

Clinical Pearls for Fundal Assessment

- **Technique:** Always support the lower uterine segment (just above the symphysis pubis) before palpating the fundus to prevent uterine inversion.

- **Documentation:** Use a systematic approach: location (e.g., U-1 for 1 cm below umbilicus, U+3 for 3 cm above), position (midline vs. displaced), and consistency (firm vs. boggy).

- **Physiological Cramping:** Educate clients that breastfeeding and fundal massage cause cramping (afterpains) due to endogenous oxytocin release, a positive sign of uterine involution.

- **Routine Frequency:** Assess fundus every 15 minutes for the first hour, every 30 minutes for the second hour, hourly for the next 4 hours, and then every 4 hours, per institutional protocol.

## 핵심 개념

- **Fundal Height** — Fundal height. It is measured by palpating the abdomen after delivery and is an important indicator for assessing uterine contraction and recovery.
- **Uterine Atony** — Uterine atony. A condition where the uterus fails to contract properly after childbirth, and it is the most common cause of postpartum hemorrhage.
- **Lochia** — Lochia. It is the discharge of shed uterine lining tissue and blood through the vagina after childbirth. It goes through three stages: Rubra (red), Serosa (serous), and Alba (white).
- **Postpartum Hemorrhage** — Postpartum hemorrhage. It refers to bleeding of 500mL or more within 24 hours after vaginal delivery, and 1000mL or more after cesarean section. The main causes include uterine atony, lacerations, retained placenta, and coagulation disorders.
- **Bladder Distention** — Bladder distension. A condition where the bladder is full of urine and expanded. After childbirth, difficulty urinating can easily occur due to anesthesia effects, perineal pain, swelling, etc., which interferes with uterine contractions and increases the risk of bleeding.

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