# A postpartum client on her second day after vaginal delivery reports increased vaginal bleeding, foul-smelling lochia, and a temperature of 101.2°F (38.4°C). Which assessment finding would be most concerning for the nurse? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=543152 > language: ko > subject: Maternal Newborn Health ## 문제 A postpartum client on her second day after vaginal delivery reports increased vaginal bleeding, foul-smelling lochia, and a temperature of 101.2°F (38.4°C). Which assessment finding would be most concerning for the nurse? ## 보기 1. Heart rate of 88 beats per minute 2. Blood pressure of 125/80 mmHg 3. Uterine fundus that is soft and boggy **✔ 정답** 4. Mild breast tenderness with breastfeeding **정답: 3** ## 해설 A soft, boggy fundus indicates uterine atony, which can cause hemorrhage and worsen infection in a patient with signs of postpartum infection. Other findings are normal or less concerning. ## 심화 해설 Clinical Context — Postpartum Complication Recognition The client’s presentation—increased vaginal bleeding, foul-smelling lochia, and a temperature of 101.2°F (38.4°C) on the second postpartum day—raises immediate concern for endometritis (infection of the uterine lining) complicated by secondary postpartum hemorrhage (PPH). While infection is a critical trigger, the most immediate threat to maternal hemodynamic stability is uncontrolled bleeding. The nurse’s assessment must rapidly identify the physiological source of the hemorrhage to guide life-saving interventions. Analysis of Answer Choices 1. Heart rate of 88 beats per minute — This is within normal limits for a postpartum client. While tachycardia is a classic compensatory sign of hypovolemia from hemorrhage, this value does not signal immediate decompensation. 2. Blood pressure of 125/80 mmHg — This is a normotensive reading. Hypotension is a late and ominous finding in PPH, indicating significant blood loss. This finding is reassuring, not concerning. 3. Uterine fundus that is soft and boggy — This is the most concerning finding. A soft, boggy (non-contracted) uterus is the hallmark of uterine atony, the leading cause of postpartum hemorrhage. The myometrial muscle fibers must remain contracted to compress the spiral arteries at the placental site; failure to do so results in rapid, uncontrolled bleeding . In the context of existing hemorrhage and infection, atony confirms a mechanical failure of hemostasis requiring immediate intervention. 4. Mild breast tenderness with breastfeeding — This is a common, expected finding associated with milk production and let-down and is unrelated to the acute hemorrhagic and infectious process. Pathophysiology and Clinical Reasoning The correct answer is option 3 because it identifies the direct mechanical cause of the client’s increased bleeding. The physiological process is as follows: after delivery of the placenta, the uterine muscle must contract to constrict the open blood vessels at the implantation site. When the uterus is atonic, these vessels remain open, leading to hemorrhage . The client’s fever and foul-smelling lochia suggest endometritis, which is a significant risk factor for uterine atony because the inflamed, infected myometrium cannot contract effectively. The clinical priority is established by the “ABC” (Airway, Breathing, Circulation) framework. A boggy fundus signals an active circulatory crisis. The nurse’s immediate actions would be to perform fundal massage to stimulate contraction, initiate uterotonic medications (e.g., oxytocin) as ordered, and prepare for escalation to mechanical interventions if the uterus remains atonic. Sources confirm that when bleeding persists despite uterotonics, mechanical methods like uterine balloon tamponade are used to apply direct pressure to the bleeding site [3,4]. The nurse’s astute assessment of fundal tone is the critical first step in this cascade, directly preventing progression to severe morbidity associated with sustained hemorrhage . This scenario highlights a key NCLEX-RN testing point: the ability to distinguish between expected postpartum findings, signs of infection, and the immediate physical indicators of life-threatening hemorrhage. While all abnormal findings must be addressed, the loss of uterine tone represents the most urgent threat to the client’s circulatory volume and requires the most rapid nursing response. ## 임상 시나리오 Clinical Scenario A postpartum client on her second day after vaginal delivery reports increased vaginal bleeding, foul-smelling lochia, and a temperature of 101.2°F (38.4°C). The nurse is performing a focused assessment to identify the most critical threat to maternal stability. Assessment Priority The immediate priority is to palpate the uterine fundus. A fundus that is soft, boggy, and non-contracted confirms **uterine atony**, the leading mechanical cause of postpartum hemorrhage. In the presence of infection (endometritis), the myometrium may fail to contract effectively, preventing compression of the spiral arteries at the placental site and leading to rapid, uncontrolled blood loss. Clinical Reasoning - **Uterine Atony:** A boggy fundus is the hallmark sign. Immediate fundal massage and uterotonic agents (e.g., oxytocin) are required to stimulate contraction and control hemorrhage. - **Vital Sign Interpretation:** A heart rate of 88 bpm and blood pressure of 125/80 mmHg are reassuring findings. Tachycardia and hypotension are late, compensatory signs of hypovolemic shock and should not be relied upon for early detection of hemorrhage. - **Source Identification:** Differentiating between bleeding from atony versus retained placental fragments or lacerations is critical. A boggy fundus localizes the source to the uterine body itself. Nursing Interventions - Immediately massage the uterine fundus to stimulate contraction. - Notify the provider and anticipate orders for uterotonic medications (e.g., oxytocin, methylergonovine, carboprost). - Maintain IV access and initiate fluid resuscitation as prescribed. - Monitor vital signs frequently for early signs of decompensation. - Assess for bladder distention, which can displace the uterus and contribute to atony. ## 핵심 개념 - **Endometritis** — Infection of the endometrium. The most common form of postpartum infection, characterized by foul-smelling lochia, fever, and uterine tenderness. - **Uterine Atony** — A condition where the uterine muscle fails to contract effectively after childbirth. It is the most common cause of postpartum hemorrhage, and a soft, boggy uterine fundus is a characteristic finding. - **Lochia** — Postpartum discharge from the uterus. Initially red (Lochia Rubra), gradually becomes pinkish (Lochia Serosa), and finally turns yellowish-white (Lochia Alba). Foul odor suggests infection. - **Boggy Uterus** — A uterus that feels soft and flabby upon palpation. This is a key clinical finding of uterine atony, whereas a firm, well-contracted uterus is normal. - **Postpartum Hemorrhage** — Excessive bleeding occurring within 24 hours after delivery (500 mL or more for vaginal delivery, 1000 mL or more for cesarean section). Uterine atony is the main cause, and infection can trigger or worsen it. ## 같은 주제 문제 - [A postpartum client on her third day after delivery presents with fever, chills, and lower…](https://mymerci.kr/pages/nclex_q.php?qn_id=543151) - [A postpartum client on her third day after vaginal delivery reports severe lower abdominal…](https://mymerci.kr/pages/nclex_q.php?qn_id=543153) - [A nurse is assessing a postpartum client 48 hours after cesarean delivery. 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