# A nurse is assessing a postpartum client 24 hours after vaginal delivery. Which assessment finding would be the priority concern requiring immediate intervention? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=543113 > language: ko > 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 intervention? ## 보기 1. Lochia rubra with small clots and mild cramping during breastfeeding 2. Fundus located 3 fingerbreadths above the umbilicus and boggy to palpation **✔ 정답** 3. Perineal edema with slight bruising around the episiotomy site 4. Breast engorgement with tenderness and warmth to touch **정답: 2** ## 해설 A boggy fundus above the umbilicus indicates uterine atony and risk of postpartum hemorrhage, requiring immediate intervention like fundal massage and oxytocin. Other findings are normal postpartum variations. ## 심화 해설 Clinical Reasoning and Priority Setting The priority concern is a fundus located 3 fingerbreadths above the umbilicus and boggy to palpation. This assessment finding is the most direct clinical indicator of uterine atony, which is the leading cause of postpartum hemorrhage (PPH). In the hierarchy of physiological needs, airway, breathing, and circulation take precedence. A boggy, displaced uterus signifies that the myometrium has failed to contract and compress the spiral arteries at the placental site, leading to active, ongoing blood loss and a high risk of rapid hemodynamic decompensation [1]. Pathophysiology and Clinical Rationale After delivery of the placenta, the uterine muscle must contract firmly to constrict the blood vessels traversing the myometrium. When the fundus is "boggy" (soft and poorly contracted) and elevated above the umbilicus, it is often filled with blood and clots, preventing effective vascular compression. This mechanical failure results in excessive blood loss. PPH is defined as cumulative blood loss exceeding 500 mL following a vaginal birth, and failure to recognize and manage the atonic uterus promptly can lead to maternal hypovolemia, tissue hypoxia, anaerobic metabolism, and ultimately multiorgan failure or cardiac arrest [1,2]. A structured, systematic evaluation is essential to identify the underlying cause—in this case, uterine atony—and to implement rapid, evidence-based interventions such as uterine massage and uterotonic therapy before the hemorrhage progresses to severe hypovolemia [2]. The finding of a firm uterine fundus with a boggy lower uterine segment can also present a discordant and challenging picture, potentially delaying hemorrhage control, which underscores why any loss of uterine tone is a critical finding [3]. Analysis of Other Options While the other findings require nursing intervention, they do not present the same immediate threat to maternal circulation and life. - Option 1 (Lochia rubra with small clots and mild cramping): This is an expected finding at 24 hours postpartum. The cramping during breastfeeding is a physiological response to endogenous oxytocin release, which promotes uterine involution, not a sign of pathology. - Option 3 (Perineal edema with slight bruising): This is a common and expected consequence of vaginal delivery and episiotomy. Routine comfort measures like ice packs are appropriate, but it does not signal a life-threatening emergency. Accurate estimation of blood loss from such sites is important, but the described finding is localized and non-emergent . - Option 4 (Breast engorgement with tenderness and warmth): This reflects the normal physiological onset of copious milk production. The warmth and tenderness are due to vascular and lymphatic congestion and are managed with breastfeeding, milk expression, and supportive measures, not emergency intervention.References (research sources) - [1]Recognition and Management of Postpartum Hemorrhage.Research articleMohamed TAEH, Chandraharan E. (2025) · DOI: 10.1097/fm9.0000000000000256 - [2]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 - [3]Beyond Standard Algorithms: Diagnostic, Procedural, and Analgesic Challenges in Refractory Postpartum Hemorrhage.Research articleLin F, Mohammed H, Khan A, Legiec JR, Rawiji H. (2026) · DOI: 10.7759/cureus.101973 ## 임상 시나리오 Clinical Management of Uterine Atony Immediate Assessment - **Fundal palpation:** A fundus that is soft, boggy, and elevated above the umbilicus (e.g., 3 fingerbreadths) suggests uterine atony with intrauterine blood accumulation. - **Vital signs:** Monitor for tachycardia, hypotension, and narrowing pulse pressure, which signal hypovolemia from ongoing blood loss. - **Lochia and perineum:** Assess for excessive vaginal bleeding, large clots, or perineal hematoma while maintaining focus on fundal tone. Priority Interventions - **Fundal massage:** Immediately perform bimanual uterine massage to stimulate contraction and expel clots. Support the lower uterine segment with one hand while massaging the fundus with the other. - **Uterotonic administration:** Administer oxytocin (Pitocin) as first-line therapy, typically 10–40 units in 500–1000 mL IV fluid at a rate to control bleeding. Consider additional agents (methylergonovine, carboprost, misoprostol) if atony persists and no contraindications exist. - **Bladder emptying:** Assist the client to void or insert a straight catheter; a distended bladder displaces the uterus and impairs contraction. - **Fluid resuscitation:** Establish large-bore IV access, administer crystalloids or blood products as ordered, and monitor intake/output closely. Ongoing Monitoring and Documentation - Reassess fundal firmness, position, and lochia every 15 minutes during the acute phase, then per institutional protocol. - Document estimated blood loss, fundal response to massage, uterotonic doses, and maternal vital signs in the medical record. - Notify the obstetric provider immediately if bleeding exceeds 500 mL or if the uterus remains boggy despite initial interventions. Differential Considerations - **Retained placental fragments:** Suspect if the fundus remains boggy after massage and uterotonics; prepare for possible uterine exploration or ultrasound. - **Coagulopathy:** Evaluate for signs of disseminated intravascular coagulation (DIC) if bleeding persists with a firm fundus; check coagulation studies and fibrinogen levels. - **Uterine inversion or rupture:** Rare but life-threatening; assess for severe pain, abnormal fundal contour, or shock disproportionate to visible blood loss. ## 핵심 개념 - **Uterine Atony** — Loss of uterine muscle tone after delivery, preventing compression of placental site blood vessels and leading to postpartum hemorrhage. - **Postpartum Hemorrhage (PPH)** — Cumulative blood loss exceeding 500 mL after vaginal birth, often caused by uterine atony, retained tissue, trauma, or coagulopathy. - **Fundal Assessment** — Palpation of the uterine fundus to evaluate its position, consistency, and height; a boggy, displaced fundus signals poor contraction and risk of bleeding. - **Boggy Fundus** — A soft, poorly contracted uterine fundus that feels spongy on palpation, indicating myometrial failure to constrict spiral arteries. - **Lochia Rubra** — Red, blood-tinged vaginal discharge lasting 1-3 days postpartum, consisting of blood, decidual tissue, and mucus; small clots are normal. ## 같은 주제 문제 - [A nurse is assessing a postpartum client 48 hours after vaginal delivery. 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