# A postpartum client delivered vaginally 2 hours ago and is experiencing heavy bleeding. The nurse assesses the fundus as boggy and displaced to the right. Vital signs are: BP 90/60 mmHg, HR 120 bpm, RR 24/min. What is the nurse's priority action? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=543148 > language: ko > subject: Maternal Newborn Health ## 문제 A postpartum client delivered vaginally 2 hours ago and is experiencing heavy bleeding. The nurse assesses the fundus as boggy and displaced to the right. Vital signs are: BP 90/60 mmHg, HR 120 bpm, RR 24/min. What is the nurse's priority action? ## 보기 1. Administer methylergonovine (Methergine) as ordered 2. Assist the client to void or catheterize if unable to void **✔ 정답** 3. Increase the IV oxytocin infusion rate 4. Massage the fundus vigorously until firm **정답: 2** ## 해설 A displaced boggy fundus suggests a full bladder preventing uterine contraction. Emptying the bladder (assist to void/catheterize) is the priority to allow fundal contraction and control bleeding. Other interventions (medications, fundal massage, IV rate increase) are secondary if bladder emptying is ineffective. ## 심화 해설 Clinical Picture A client who delivered vaginally 2 hours ago is experiencing heavy postpartum bleeding. The fundus is boggy and displaced to the right, with vital signs of BP 90/60 mmHg, HR 120 bpm, and RR 24/min. This presentation points to postpartum hemorrhage secondary to uterine atony, complicated by a full bladder. Step-by-Step Analysis The scenario describes a classic case of early postpartum hemorrhage. The boggy uterus indicates uterine atony, the leading cause of postpartum bleeding. The fundus being displaced to the right and above the umbilicus is a key clinical sign of a distended bladder. A full bladder mechanically displaces the uterus and prevents it from contracting effectively, directly contributing to the atony and subsequent bleeding. The vital signs—hypotension and tachycardia—indicate the client is progressing to hypovolemic shock from blood loss, making immediate intervention critical. The priority action must address the underlying cause of the atony in this specific situation. The provided rationale material, while focused on equine antimicrobial stewardship, does not contain information relevant to human postpartum care. Therefore, the clinical reasoning is based on standard, evidence-based nursing protocols for postpartum hemorrhage, which dictate a sequence of interventions from least to most invasive and addressing the most correctable cause first. 1. Option 1: Administer methylergonovine (Methergine) as ordered. Methylergonovine is a potent uterotonic agent that causes sustained uterine contractions. However, it is contraindicated in clients with hypertension and is not the first-line action when a mechanical cause like a full bladder is present. Administering a medication without first correcting the bladder distention is ineffective and potentially dangerous if the drug is not indicated. The priority is to remove the physical barrier to uterine contraction. 2. Option 2: Assist the client to void or catheterize if unable to void. This is the correct priority action. A full bladder is the direct mechanical cause of the uterine displacement and a primary contributor to the atony. Emptying the bladder removes this obstacle, allowing the uterus to contract naturally and descend back into the pelvis. This is a non-invasive, foundational step that must be performed before or concurrently with fundal massage. If the client cannot void spontaneously, straight catheterization is necessary to provide immediate relief. 3. Option 3: Increase the IV oxytocin infusion rate. Oxytocin is the first-line pharmacologic agent for uterine atony and is often already running post-delivery. While increasing the infusion rate is a standard intervention for atony, it is not the priority action here. The bogginess is being caused by a full bladder; no amount of oxytocin will effectively contract a uterus that is mechanically displaced and blocked by a distended bladder. The mechanical obstruction must be removed first for the medication to be effective. 4. Option 4: Massage the fundus vigorously until firm. Fundal massage is a critical intervention for a boggy uterus. However, performing it on a uterus displaced by a full bladder is not only ineffective but can also be painful and potentially cause uterine inversion or increased bleeding. The standard protocol is to first empty the bladder to allow the uterus to return to its proper midline position, and then perform fundal massage to stimulate contraction. Massaging a displaced fundus is contraindicated. The sequence of nursing actions for a boggy, displaced fundus is clear: first, empty the bladder; second, massage the fundus; third, administer or increase uterotonic medications as ordered. Addressing the root cause—the distended bladder—is the immediate priority. ## 임상 시나리오 Clinical Priority for Postpartum Hemorrhage with Displaced Fundus **Scenario:** A client presents with heavy bleeding 2 hours post-vaginal delivery. The fundus is boggy and displaced to the right. Vital signs indicate hypovolemia (BP 90/60, HR 120). Clinical Reasoning Guide The assessment reveals **uterine atony** complicated by a **distended bladder**. The fundal displacement is the critical clue. A full bladder mechanically prevents the uterus from contracting effectively. The priority is to remove this mechanical obstruction using the least invasive method first. Step-by-Step Nursing Intervention - **First Action: Empty the Bladder** - Assist the client to void. Provide privacy, run water, or use other measures to stimulate urination. - If the client is unable to void within a specified timeframe, perform straight catheterization as ordered to immediately relieve the distention. - **Second Action: Fundal Massage** - Once the bladder is empty, immediately reassess the fundus. It should be midline and firm. - If the fundus remains boggy, begin fundal massage by cupping one hand above the symphysis pubis and massaging the fundus with the other until it firms. - **Third Action: Uterotonic Medications** - If massage is ineffective, initiate or increase the rate of IV oxytocin (Pitocin) as per standing orders. This is the first-line pharmacologic agent. - Administer additional uterotonics like methylergonovine (Methergine) only if ordered and after confirming the absence of contraindications such as hypertension. Clinical Pearls - **Assessment Sequence:** Always assess the bladder first when a fundus is displaced from the midline. The sequence is: Bladder, then Massage, then Medication. - **Safety Alert:** Never massage a uterus over a full bladder. This is ineffective and can increase the risk of uterine inversion or exacerbate discomfort. - **Ongoing Monitoring:** Continuously monitor vital signs, amount of bleeding (weigh pads), and fundal tone. The client’s tachycardia and hypotension require immediate fluid resuscitation and continuous evaluation for shock. ## 핵심 개념 - **Uterine Atony** — Loss of uterine muscle tone, the most common cause of early postpartum hemorrhage, resulting in a soft or boggy fundus. - **Boggy Fundus** — A uterus that feels soft and poorly contracted upon palpation, indicating a lack of muscle tone and risk of hemorrhage. - **Fundal Displacement** — A uterus deviated from the midline, often to the right and above the umbilicus, classically caused by a distended bladder. - **Postpartum Hemorrhage (PPH)** — Cumulative blood loss of 1000 mL or more, or blood loss accompanied by signs of hypovolemia within 24 hours of birth. - **Hypovolemic Shock** — A life-threatening condition caused by a significant loss of blood or fluids, leading to inadequate tissue perfusion, manifested by hypotension and tachycardia. ## 같은 주제 문제 - [A nurse is assessing a 32-year-old multipara who delivered vaginally 2 hours ago after a r…](https://mymerci.kr/pages/nclex_q.php?qn_id=543143) - [A nurse is caring for a 25-year-old client who delivered her second baby vaginally 2 hours…](https://mymerci.kr/pages/nclex_q.php?qn_id=543144) - [A postpartum client delivered vaginally 2 hours ago and is experiencing heavy bleeding. 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