# A nurse is assessing a 32-year-old multipara who delivered vaginally 2 hours ago after a rapid labor of 4 hours. Which assessment finding would be the MOST concerning and require immediate intervention?

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> subject: Maternal Newborn Health

## 문제

A nurse is assessing a 32-year-old multipara who delivered vaginally 2 hours ago after a rapid labor of 4 hours. Which assessment finding would be the MOST concerning and require immediate intervention?

The nurse is monitoring a 28-year-old primigravida who had a normal vaginal delivery 2 hours ago after a prolonged labor of 18 hours.

## 보기

1. Fundus palpated 2 fingerbreadths above the umbilicus and slightly to the right
2. Lochia rubra with small clots and saturating one pad per hour
3. Blood pressure 88/50 mmHg with heart rate 120 bpm and client reports feeling dizzy **✔ 정답**
4. Perineal edema with moderate discomfort rated 6/10 on pain scale

**정답: 3**

## 해설

Hypotension, tachycardia, and dizziness indicate hemorrhagic shock requiring immediate intervention. Other findings like fundus position or lochia are less urgent in this context.

## 심화 해설

Clinical Reasoning Analysis

The most concerning assessment finding is blood pressure 88/50 mmHg with heart rate 120 bpm and the client reporting dizziness. This combination of hypotension, tachycardia, and subjective dizziness represents the classic clinical triad of hypovolemic shock, a life-threatening emergency requiring immediate intervention.

In the context of a postpartum patient, these vital sign changes are the earliest and most critical indicators of excessive blood loss. The body compensates for a significant reduction in circulating volume by increasing the heart rate to maintain cardiac output. When this compensatory mechanism begins to fail, the blood pressure drops, and cerebral perfusion decreases, leading to the sensation of dizziness. This presentation directly aligns with the core principle highlighted in the provided evidence that early recognition of postpartum hemorrhage is essential to prevent progression to severe hypovolemia and organ dysfunction [2]. A patient presenting with these signs is no longer simply at risk; she is actively decompensating.

While the other options represent abnormal findings that require further nursing action, they do not signal an immediate, life-threatening state of shock.

Why the Other Options Are Less Concerning

Option 1: A fundus that is palpated 2 fingerbreadths above the umbilicus and deviated to the right is a classic sign of a distended bladder. A full bladder mechanically displaces the uterus and prevents it from contracting effectively, which is a primary cause of early postpartum hemorrhage. This finding is highly significant and demands immediate nursing action—assisting the client to void or performing straight catheterization. However, the finding itself is a precursor to hemorrhage, not a sign of active, decompensated shock. The intervention is to empty the bladder and then reassess fundal tone and position.

Option 2: Lochia rubra with small clots and saturating one pad per hour is a finding that falls on the boundary between normal and excessive bleeding. The standard definition of postpartum hemorrhage often includes blood loss that saturates a perineal pad in 15 minutes or less, or a volume greater than 500 mL. A saturation rate of one pad per hour warrants continuous close monitoring and notification of the healthcare provider, but it does not, in isolation, indicate a hemodynamic crisis. The patient’s vital signs in this option are not reported as unstable, which is the key differentiator from the correct answer.

Option 4: Perineal edema with moderate discomfort rated 6/10 on the pain scale is an expected finding after a vaginal delivery, especially following a prolonged labor. However, the case report on puerperal hematoma provides a critical caution: severe perineal pain can be the first and only early sign of a concealed vulvovaginal hematoma, which can lead to massive blood loss and hypovolemia . Therefore, while a pain score of 6/10 is not inherently alarming, the nurse must perform a thorough perineal assessment to rule out a tense, bulging, discolored mass that would indicate a developing hematoma. The finding of "moderate discomfort" without signs of a hematoma or unstable vital signs makes this a lower priority than the clear signs of shock in Option 3.

Pathophysiological and Clinical Integration

The two clinical scenarios—a rapid labor and a prolonged labor—both increase the risk for postpartum hemorrhage due to uterine atony, but the assessment priority remains the same: a systematic evaluation using a structured clinical approach to identify the underlying cause of deterioration [2]. The nurse must differentiate between a potential cause of hemorrhage (a full bladder, a concerning lochia flow), a potential concealed source of hemorrhage (pain that could indicate a hematoma), and the systemic consequence of uncontrolled hemorrhage (hypovolemic shock). The vital signs in Option 3 indicate that the patient has already progressed to the consequence stage, where compensatory mechanisms are failing. This demands the most immediate intervention, which includes calling for help, initiating rapid intravenous fluid resuscitation, administering uterotonic medications as ordered, and preparing for potential surgical intervention, consistent with the principles of early recognition and rapid implementation of therapeutic strategies to prevent organ dysfunction [2].References (research sources)

- [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

## 임상 시나리오

Clinical Practice Guide: Recognizing Postpartum Hemorrhage

Key Assessment Findings

The classic triad of **hypotension (BP 88/50 mmHg)**, **tachycardia (HR 120 bpm)**, and **dizziness** in a postpartum patient indicates active decompensation from hypovolemic shock, most commonly due to postpartum hemorrhage. This represents a failure of compensatory mechanisms and requires immediate intervention to prevent organ dysfunction and death.

Immediate Nursing Actions

- Call for emergency assistance and activate the facility's massive transfusion or obstetric emergency protocol.

- Administer high-flow oxygen via non-rebreather mask to maximize oxygen delivery to tissues.

- Ensure two large-bore intravenous lines are in place and begin rapid infusion of isotonic crystalloids (e.g., Lactated Ringer's or Normal Saline) as ordered.

- Perform continuous maternal vital sign monitoring and pulse oximetry every 5-15 minutes.

- Initiate fundal massage if uterine atony is suspected, and prepare to administer uterotonic medications (e.g., oxytocin, methylergonovine, carboprost).

Differential Assessment

**Distended Bladder:** A fundus displaced above the umbilicus and to the right indicates bladder distention, not hemorrhage. Assist the patient to void or perform straight catheterization, then reassess fundal position and bleeding.

**Expected Lochia:** Saturating one pad per hour with small clots is within normal limits for the first few hours postpartum. Continue to monitor quantity, color, and presence of clots.

**Perineal Discomfort:** Edema and pain rated 6/10 are common after vaginal delivery. Apply ice packs, administer analgesics, and provide comfort measures, but this does not signal a life-threatening emergency.

Clinical Pearls

Tachycardia is often the earliest vital sign change in hemorrhage. A rising heart rate with a narrowing pulse pressure precedes a drop in systolic blood pressure. Do not wait for hypotension to intervene. Quantify blood loss using calibrated drapes or weighing saturated items rather than visual estimation.

## 핵심 개념

- **Hypovolemic Shock** — A life-threatening condition caused by a significant loss of blood or fluids, leading to inadequate tissue perfusion and oxygenation.
- **Lochia Rubra** — The vaginal discharge after childbirth consisting of blood, mucus, and uterine tissue, which is typically red and heavy for the first 3-4 days.
- **Fundal Assessment** — Palpation of the uterine fundus to evaluate its firmness, position, and height, which helps assess for uterine atony and bladder distention.

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