# A nurse is assessing a client who is 72 hours postpartum following a cesarean delivery. Which assessment finding would be the priority concern requiring immediate intervention?

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> subject: Maternal Newborn Health

## 문제

A nurse is assessing a client who is 72 hours postpartum following a cesarean delivery. Which assessment finding would be the priority concern requiring immediate intervention?

## 보기

1. Lochia rubra with clots larger than a quarter and soaking one pad per hour **✔ 정답**
2. Breast engorgement with mild tenderness and warmth
3. Incision site with slight edema and minimal discomfort
4. Uterine fundus palpated at the level of the umbilicus and firm

**정답: 1**

## 해설

Lochia rubra with large clots and soaking one pad per hour indicates postpartum hemorrhage, a medical emergency requiring immediate intervention. Other findings are normal postpartum variations.

## 심화 해설

Clinical Reasoning and Priority Setting

The correct answer is Option 1. In the postpartum period, especially following a cesarean delivery, the nurse must constantly differentiate between expected physiological changes and pathological deviations. The priority concern is a finding that suggests a life-threatening complication requiring immediate intervention.

Analysis of the Correct Answer

Lochia rubra with clots larger than a quarter and soaking one pad per hour is the definition of postpartum hemorrhage (PPH). While a cesarean delivery involves a controlled surgical incision, the placental separation site on the uterine wall remains a large, raw vascular area. After 72 hours, the uterine muscle should be contracting firmly to compress these vessels. The presence of large clots indicates that blood is pooling and coagulating within the uterus or vagina faster than the body's fibrinolytic system can break it down, which is a sign of excessive bleeding. A saturation rate of one pad per hour quantitatively defines a hemorrhage. The immediate risk is hypovolemic shock, a critical condition where the circulating blood volume is insufficient to perfuse vital organs. Evidence from a retrospective study on PPH outcomes confirms that physiological indicators are crucial for early recognition of hemorrhage severity, as estimated blood loss alone can be inaccurate [4]. Furthermore, a synthesis of best practices for PPH management emphasizes that early recognition through quantitative assessment of blood loss is a cornerstone of effective intervention . This finding demands immediate fundal massage, notification of the provider, and preparation for pharmacological or fluid resuscitation interventions.

Analysis of Incorrect Options

Option 2: Breast engorgement with mild tenderness and warmth.

This is an expected physiological process as mature milk transitions in around 72 hours postpartum. The distention of the mammary glands with milk and increased vascular and lymphatic circulation causes the breasts to become full, tender, and warm to the touch. While uncomfortable for the client, this is a normal finding that is managed with non-pharmacological comfort measures like frequent feeding or pumping, cold compresses between feeds, and a well-fitted bra. It does not indicate a systemic or life-threatening complication.

Option 3: Incision site with slight edema and minimal discomfort.

A surgical incision triggers the inflammatory phase of wound healing. Slight, localized edema is an expected result of increased capillary permeability, allowing fluid and immune cells to migrate to the tissue. Minimal discomfort at the site is also normal and should be well-controlled with prescribed analgesics. This finding would become a concern only if it were accompanied by signs of infection (purulent drainage, spreading erythema, fever) or wound dehiscence, which are not present here.

Option 4: Uterine fundus palpated at the level of the umbilicus and firm.

Immediately after delivery, the uterine fundus is typically located at or slightly below the umbilicus. By 72 hours postpartum, the process of involution should have caused the fundus to descend by approximately one fingerbreadth (1 cm) per day. A fundus that is still at the umbilical level on day three is slightly higher than the expected position. However, the critical descriptive word here is "firm." A well-contracted, firm fundus indicates that the myometrial muscles are effectively clamping down on the blood vessels at the placental site, which is the primary physiological mechanism for preventing PPH. A boggy or soft uterus would be a major concern, but a firm uterus, even if slightly high, is a reassuring finding that does not signal an immediate emergency. The slight delay in descent could be due to a full bladder, which would be the nurse's next assessment step.References (research sources)

- [4]Combining the Lactate Level and Shock Index for Predicting Postpartum Hemorrhage Outcomes: An 11-Year Retrospective Study.Research articleCha Y, Yang E. (2026) · DOI: 10.1016/j.jen.2026.05.004

## 임상 시나리오

Clinical Case: Recognizing Postpartum Hemorrhage

**Scenario:** A 32-year-old G2P2 patient at 72 hours post-cesarean delivery reports feeling "wet" and dizzy. The nurse assesses the patient and finds the perineal pad fully saturated with bright red blood and clots larger than a quarter.

**Clinical Pearl:** Early recognition of excessive bleeding is critical. A single episode of saturating one pad in an hour, especially with large clots, is a quantitative trigger for PPH evaluation regardless of the delivery method. The placental separation site remains a vascular wound susceptible to atony or retained fragments even after a controlled surgical delivery.

**Immediate Actions:**

- Initiate fundal massage immediately to promote uterine contraction and expel clots.

- Notify the provider and activate the facility's obstetric emergency protocol.

- Increase IV fluid rate (e.g., Lactated Ringer's) as ordered to maintain circulating volume.

- Monitor vital signs every 5-15 minutes, focusing on signs of hypovolemic shock (tachycardia, hypotension).

- Assess bladder distention; assist with voiding or catheterize, as a full bladder can displace the uterus and inhibit contraction.

- Quantify blood loss by weighing pads and linens (1 gram = 1 mL blood loss).

**Differentiating from Normal Findings:**

- **Lochia:** Expected to be rubra (red) for 3-4 days, but flow should be moderate and decreasing, not saturating a pad hourly.

- **Fundus:** At 72 hours, a firm fundus is expected 2-3 fingerbreadths below the umbilicus. A boggy or displaced fundus suggests atony or a full bladder.

- **Incision:** Mild edema and discomfort are normal; however, increasing pain, purulent drainage, or erythema would signal infection.

## 핵심 개념

- **Postpartum Hemorrhage (PPH)** — Cumulative blood loss greater than 1000 mL or bleeding accompanied by signs of hypovolemia within 24 hours of birth; primary indicator includes saturation of one perineal pad per hour.
- **Lochia Rubra** — The first stage of postpartum vaginal discharge consisting of blood, decidual tissue, and mucus, lasting approximately 3 to 4 days after delivery.
- **Uterine Involution** — The physiological process by which the uterus returns to its pre-pregnancy size and condition; the fundus descends approximately one fingerbreadth per day.

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