# A nurse is assessing a 32-year-old multipara 24 hours after vaginal delivery of twins. Which assessment finding requires the nurse's immediate attention?

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> subject: Maternal Newborn Health

## 문제

A nurse is assessing a 32-year-old multipara 24 hours after vaginal delivery of twins. Which assessment finding requires the nurse's immediate attention?

The nurse is conducting a comprehensive postpartum assessment on a client who delivered vaginally 24 hours ago.

## 보기

1. Fundus located 2 cm above the umbilicus and deviated to the right side **✔ 정답**
2. Lochia rubra with small clots and a mild odor
3. Breast engorgement with bilateral tenderness
4. Perineal edema with intact sutures

**정답: 1**

## 해설

A fundus above the umbilicus and deviated to the right indicates bladder distention requiring immediate intervention to prevent postpartum hemorrhage. Other findings are expected or less urgent postpartum conditions.

## 심화 해설

Clinical Reasoning and Priority Setting

The correct answer is Fundus located 2 cm above the umbilicus and deviated to the right side. In the context of a client who is 24 hours post-vaginal delivery of twins, this assessment finding represents a classic sign of a distended bladder, which is the most common cause of uterine atony and subsequent postpartum hemorrhage (PPH).

Pathophysiology and Mechanism

The finding of a fundus that is elevated above the expected level (which should be at or one fingerbreadth below the umbilicus at 24 hours) and deviated laterally, typically to the right, indicates that a full bladder is displacing the uterus. A distended bladder mechanically impedes the uterine muscle's ability to contract effectively and compress the open vessels at the former placental site. This impaired contractility, known as uterine atony, is the leading cause of PPH. The risk of atony is inherently higher in this client due to uterine overdistention from the twin pregnancy. As noted in the foundational research on uterine physiology, uterine overdistention is a well-established trigger for dysfunctional labor and postpartum contractility issues, mediated in part by inflammatory pathways [3]. If the bladder is not promptly emptied, the resulting atony can lead to rapid blood loss, which aligns with the contemporary emphasis on early recognition of PPH to prevent progression to severe hypovolemia [4].

Analysis of Incorrect Options

-   Option 2: Lochia rubra with small clots and a mild odor. This is an expected finding at 24 hours postpartum. Lochia rubra is the normal vaginal discharge consisting of blood, decidual tissue, and mucus. Small clots are common, especially after the uterus has been at rest, and a mild, fleshy odor is normal. A foul odor would be concerning for endometritis, but that is not described here.

-   Option 3: Breast engorgement with bilateral tenderness. This is a normal physiological process as the milk supply transitions from colostrum to mature milk, typically occurring around day 3 to 5 postpartum. While it can occur earlier, bilateral tenderness and fullness at 24 hours are an expected finding and do not constitute an immediate threat to physiological safety.

-   Option 4: Perineal edema with intact sutures. Following a vaginal delivery, especially of twins, some degree of perineal edema is an expected inflammatory response to tissue trauma. The priority assessment is that the sutures are intact, indicating the repair is holding. While ice packs and comfort measures are indicated, this finding does not signal a life-threatening emergency.

Clinical Priority and Nursing Action

The nurse must prioritize findings using the "ABCs" (Airway, Breathing, Circulation) and safety framework. A boggy, displaced uterus is a direct precursor to hemorrhage and circulatory collapse. The immediate nursing intervention is to assist the client to void or perform a straight catheterization if she cannot void spontaneously, then reassess the fundus for firmness and position. This directly addresses the most common reversible cause of early PPH, a principle critical to the systematic evaluation and rapid implementation of therapeutic strategies in obstetric emergencies [4].References (research sources)

- [3]Uterine overdistention induces preterm labor mediated by inflammation: observations in pregnant women and nonhuman primates.Research articleAdams Waldorf KM, Singh N, Mohan AR, Young RC, Ngo L, Das A, Tsai J, Bansal A, Paolella L, Herbert BR, Sooranna SR, Gough GM, Astley C, Vogel K, Baldessari AE, Bammler TK, MacDonald J, Gravett MG, Rajagopal L, Johnson MR. (2015) · DOI: 10.1016/j.ajog.2015.08.028

- [4]Contemporary Approach to Postpartum Hemorrhage: Early Diagnosis and Evidence-Based Therapeutic Management.Research articleZúñiga Gómez E, Durán Monge PR, Castro Rivero LC. (2026) · DOI: 10.7759/cureus.107095

## 임상 시나리오

Clinical Scenario

A 32-year-old G2P2 who delivered twins vaginally 24 hours ago is undergoing a routine postpartum assessment. The nurse palpates the fundus and finds it 2 cm above the umbilicus and deviated to the right side.

Priority Nursing Action

- **Immediate intervention:** Assist the client to empty her bladder completely, either by ambulation to the bathroom or via straight catheterization if unable to void spontaneously.

- **Reassessment:** Immediately after bladder emptying, re-palpate the fundus. It should descend to the level of the umbilicus or one fingerbreadth below and be midline and firm. If the fundus remains boggy (soft), perform fundal massage to stimulate contraction.

- **Monitor for hemorrhage:** Assess vital signs for tachycardia and hypotension, and evaluate lochia flow. A full bladder is the most common cause of uterine atony, which can rapidly lead to postpartum hemorrhage, especially in a client with a distended uterus from a twin pregnancy.

Expected vs. Abnormal Findings at 24 Hours Postpartum

| Assessment Parameter | Expected Finding | Abnormal Finding |
| --- | --- | --- |
| Fundal Height | At or 1 fingerbreadth below umbilicus | Above umbilicus or deviated laterally |
| Fundal Consistency | Firm, midline | Boggy (soft) or displaced |
| Lochia | Rubra, moderate, small clots, fleshy odor | Heavy saturation (>1 pad/hr), large clots, foul odor |
| Bladder | Non-palpable, voiding freely | Distended, palpable above symphysis pubis |

Clinical Reasoning

The elevated and deviated fundus is a classic sign of bladder distention. A full bladder mechanically displaces the uterus and prevents effective myometrial contraction, leading to uterine atony. Given the client's risk factor of uterine overdistention from a twin gestation, failure to promptly empty the bladder can precipitate rapid, life-threatening postpartum hemorrhage. This finding takes priority over normal postpartum changes such as lochia rubra, breast engorgement, or perineal edema.

## 핵심 개념

- **Uterine Atony** — Loss of uterine muscle tone causing inability to contract and compress blood vessels, the leading cause of postpartum hemorrhage.
- **Fundal Assessment** — Palpation of the uterine fundus to evaluate height, position, and firmness; a boggy, elevated, or deviated fundus indicates atony or bladder distention.
- **Lochia Rubra** — Red, bloody vaginal discharge consisting of blood and decidual debris, normal for the first 3-4 days postpartum.
- **Postpartum Hemorrhage (PPH)** — Cumulative blood loss >1000 mL or signs/symptoms of hypovolemia within 24 hours of birth, often caused by uterine atony.

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