# A nurse is assessing a postpartum client 2 hours after vaginal delivery. Which assessment finding would be the most concerning indicator of uterine atony requiring immediate intervention? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=543135 > language: ko > subject: Maternal Newborn Health ## 문제 A nurse is assessing a postpartum client 2 hours after vaginal delivery. Which assessment finding would be the most concerning indicator of uterine atony requiring immediate intervention? ## 보기 1. Fundus palpated 2 cm above the umbilicus and slightly to the right 2. Fundus soft and boggy with continuous moderate vaginal bleeding **✔ 정답** 3. Lochia rubra with small clots present 4. Mild cramping with fundus firm at umbilical level **정답: 2** ## 해설 A soft, boggy fundus with continuous bleeding is the classic sign of uterine atony requiring immediate intervention like fundal massage and uterotonics. Other findings (e.g., fundus position, normal lochia, firm fundus) are expected or less urgent in postpartum assessment. ## 심화 해설 Clinical Context & Correct Answer Rationale The most concerning finding is a soft and boggy fundus with continuous moderate vaginal bleeding. This presentation is the classic clinical hallmark of uterine atony, which is the failure of the uterine muscle to contract and compress the open blood vessels at the placental site after delivery. Uterine atony is the single most common cause of postpartum hemorrhage (PPH), an obstetric emergency defined as blood loss exceeding 500 mL after vaginal birth [1]. A soft, non-contracted uterus cannot effectively clamp down on the spiral arteries and venous sinuses, leading to persistent and potentially life-threatening blood loss. Without immediate intervention, the loss of blood volume and oxygen-carrying capacity can rapidly progress to maternal hypovolemia, tissue hypoxia, anaerobic metabolism, and multiorgan failure [1]. The priority nursing action is immediate fundal massage and notification of the provider for initiation of uterotonic medications. Analysis of Incorrect Options - Option 1: A fundus palpated 2 cm above the umbilicus and slightly to the right is a significant finding, but it is most indicative of a distended bladder, not primary uterine atony. A full bladder can displace the uterus upward and to the right and can prevent it from contracting firmly, thus it is a contributing factor to atony. The immediate intervention is to assist the client to void, then reassess the fundus. While important, the finding itself is not the direct indicator of atony like a boggy fundus is. - Option 3: Lochia rubra with small clots is a normal finding in the immediate postpartum period. The presence of small clots is expected as blood pools in the vagina and coagulates. This finding alone, without a description of a boggy fundus or excessive flow, does not signal a hemorrhage. - Option 4: Mild cramping with a fundus that is firm and at the umbilical level is a normal postpartum assessment. The cramping, known as "afterpains," is caused by the uterus contracting to remain firm and control bleeding. A firm fundus at the umbilicus is the desired finding and indicates that the myometrium is effectively compressing the vessels. Pathophysiology & Clinical Management Deep Dive The underlying mechanism of uterine atony involves the failure of the myometrium to contract and retract effectively after placental separation. Normally, contraction of the interlacing muscle fibers constricts the blood vessels that supplied the placental bed, a process often termed the "living ligature." When the muscle is atonic, it remains soft and boggy, allowing continuous bleeding from the open vasculature. The management of PPH from uterine atony follows a structured, stepwise approach . The initial steps, which the nurse performs or initiates, include fundal massage and ensuring the bladder is empty. If bleeding persists despite these mechanical interventions, pharmacologic management with uterotonic agents like Pitocin is the next critical step to stimulate uterine contraction . If first-line uterotonics fail, the clinical team may escalate to intrauterine tamponade devices, such as the JADA System, which applies low-level vacuum to collapse the uterine cavity and control bleeding [2,3]. Early recognition of the boggy fundus by the nurse is the pivotal trigger that activates this entire life-saving chain of interventions, preventing progression to severe hypovolemia and its catastrophic sequelae .References (research sources) - [1]Recognition and Management of Postpartum Hemorrhage.Research articleMohamed TAEH, Chandraharan E. (2025) · DOI: 10.1097/fm9.0000000000000256 ## 임상 시나리오 Clinical Scenario A 32-year-old G2P2 client delivered a 4.1 kg infant vaginally 2 hours ago. The nurse performs a routine postpartum fundal assessment and notes the uterus is soft and boggy upon palpation. The client is experiencing continuous moderate vaginal bleeding, saturating one perineal pad in 15 minutes. Vital signs: BP 100/62 mmHg, HR 108 bpm, RR 20/min, SpO2 97% on room air. Immediate Nursing Actions - **Initiate fundal massage immediately.** Support the lower uterine segment with one hand just above the symphysis pubis while using the other hand to firmly massage the fundus in a circular motion until it becomes firm. This mechanical stimulation promotes contraction and expulsion of accumulated clots. - **Notify the provider urgently.** Report the boggy fundus, estimated blood loss, and current vital signs. Anticipate orders for uterotonic medications such as oxytocin, methylergonovine, or carboprost tromethamine. - **Assess for bladder distention.** A full bladder can displace the uterus and prevent contraction. Assist the client to void or prepare for straight catheterization if unable to void spontaneously, then reassess fundal tone. - **Increase IV fluid rate** as ordered using a large-bore catheter to maintain circulating volume and prevent hypovolemic shock. - **Monitor vital signs every 5 to 15 minutes** and apply oxygen via non-rebreather mask if signs of hypoxia or hemodynamic instability develop. Ongoing Assessment and Monitoring - **Quantify blood loss** by weighing saturated pads and linens (1 gram = 1 mL blood loss). Document cumulative blood loss to guide transfusion decisions. - **Reassess fundal tone every 5 to 15 minutes** after massage to ensure sustained contraction. A fundus that repeatedly becomes boggy suggests ongoing atony requiring pharmacologic intervention. - **Monitor for signs of shock** including tachycardia, hypotension, pallor, cool clammy skin, altered mental status, and decreased urine output (less than 30 mL/hour). - **Evaluate lochia** for color, amount, and presence of clots. Saturation of one pad in less than 15 minutes or pooling of blood under the buttocks indicates active hemorrhage. Pharmacologic Management - **Oxytocin (Pitocin):** First-line uterotonic, administered as 10-40 units in 500-1000 mL IV fluid as a continuous infusion or 10 units IM. Contraindicated only in hypersensitivity. - **Methylergonovine (Methergine):** 0.2 mg IM every 2-4 hours. Contraindicated in hypertension, preeclampsia, or cardiovascular disease due to vasoconstrictive effects. - **Carboprost tromethamine (Hemabate):** 250 mcg IM every 15-90 minutes (maximum 8 doses). Contraindicated in asthma due to bronchoconstrictive effects. - **Misoprostol (Cytotec):** 800-1000 mcg rectally as a single dose. Used when other uterotonics are unavailable or contraindicated. Complications and Escalation - **Refractory uterine atony** unresponsive to massage and uterotonics may require intrauterine balloon tamponade (Bakri balloon), uterine artery embolization, or surgical interventions including B-Lynch suture or hysterectomy. - **Disseminated intravascular coagulation (DIC)** can develop with massive hemorrhage. Monitor coagulation studies (PT, aPTT, fibrinogen) and transfuse blood products as ordered. - **Sheehan syndrome** (postpartum pituitary necrosis) may occur due to severe hypotension causing ischemic damage to the anterior pituitary, resulting in failure of lactation and amenorrhea. Documentation and Communication - Document fundal assessment findings (tone, position, height), characteristics of lochia, perineal pad count and saturation, vital signs, and interventions performed with client response. - Communicate clearly with the provider using SBAR format: Situation (active postpartum hemorrhage), Background (2 hours post vaginal delivery, boggy fundus), Assessment (estimated blood loss, vital signs), Recommendation (request orders for uterotonics and labs). - Provide emotional support to the client and family, explaining all interventions calmly and answering questions to reduce anxiety during the emergency. ## 핵심 개념 - **Uterine Atony** — Failure of the uterine muscle to contract after delivery, preventing compression of blood vessels at the placental site and leading to postpartum hemorrhage. - **Postpartum Hemorrhage (PPH)** — Cumulative blood loss greater than 500 mL after vaginal delivery or 1000 mL after cesarean, most commonly caused by uterine atony. - **Fundal Massage** — A first-line nursing intervention for a boggy uterus, involving circular or firm downward pressure on the uterine fundus to stimulate contraction and expel clots. - **Lochia Rubra** — The normal vaginal discharge after delivery consisting of blood, mucus, and tissue debris, lasting for the first 3 to 4 days postpartum. ## 같은 주제 문제 - [A postpartum nurse is assessing a client 2 hours after vaginal delivery. 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