# Situation: A nurse works in the labor room of a government birthing facility that provides basic emergency obstetric and newborn care (BEmONC). Two midwives and a nursing attendant share the night shift with the nurse. At the start of the shift, the nurse receives endorsement of four women. Which woman should the nurse assess FIRST? Woman 1: primigravida, 5 cm dilated, contractions every 4 minutes, fetal heart rate 144 beats per minute, pain 8/10, asking for pain relief Woman 2: gave birth 60 minutes ago; fundus firm at the umbilicus; moderate lochia rubra; asking for help with breastfeeding Woman 3: multigravida at 39 weeks, 3 cm dilated, admitted 30 minutes ago, crying and afraid of the birth Woman 4: gave birth 90 minutes ago; fundus soft and boggy 2 cm above the umbilicus; saturated one pad in 15 minutes; says she only feels tired

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=629409  
> language: ko  
> subject: Nursing Practice II — Maternal and Child Health Nursing

## 문제

Situation: A nurse works in the labor room of a government birthing facility that provides basic emergency obstetric and newborn care (BEmONC). Two midwives and a nursing attendant share the night shift with the nurse.

At the start of the shift, the nurse receives endorsement of four women. Which woman should the nurse assess FIRST?
Woman 1: primigravida, 5 cm dilated, contractions every 4 minutes, fetal heart rate 144 beats per minute, pain 8/10, asking for pain relief
Woman 2: gave birth 60 minutes ago; fundus firm at the umbilicus; moderate lochia rubra; asking for help with breastfeeding
Woman 3: multigravida at 39 weeks, 3 cm dilated, admitted 30 minutes ago, crying and afraid of the birth
Woman 4: gave birth 90 minutes ago; fundus soft and boggy 2 cm above the umbilicus; saturated one pad in 15 minutes; says she only feels tired

## 보기

1. Woman 1
2. Woman 2
3. Woman 3
4. Woman 4 **✔ 정답**

**정답: 4**

## 해설

Woman 4 has a soft, boggy fundus above the umbilicus and has saturated a pad in 15 minutes, which point to uterine atony with active postpartum bleeding. Her remark that she only feels tired does not make her stable; heavy bleeding is an unexpected, potentially life-threatening change. The other women have expected findings or needs of lower priority.

## 심화 해설

Priority setting in the labor room

The first step is to recognize that this question tests triage and prioritization in a low-resource BEmONC setting. The nurse must identify which woman has a life-threatening, unexpected change requiring immediate intervention rather than an expected finding or a psychosocial need.

Why Woman 4 is the priority

Woman 4 presents with three findings that together point to uterine atony with active postpartum hemorrhage: a soft and boggy fundus, a fundal height 2 cm above the umbilicus, and saturation of one pad in 15 minutes. A firm, contracted uterus compresses the spiral arteries at the placental site and is the primary physiologic mechanism that limits bleeding after birth. When the myometrium fails to contract, these vessels remain open, and blood loss can become rapid and sustained [2].

The saturated pad is the most objective sign of active bleeding. In a BEmONC facility without advanced surgical backup, early recognition of atony is critical because the window for effective intervention with uterotonics, bimanual compression, and fluid resuscitation narrows quickly [2]. The woman’s statement that she “only feels tired” is a subtle but important cue: fatigue can be an early manifestation of hypovolemia and reduced oxygen-carrying capacity, not a reassuring sign [2]. Postpartum hemorrhage is defined as blood loss exceeding 500 mL after vaginal birth, and the progression from compensated to decompensated shock can be rapid [2].

Why the other women are lower priority

| Woman | Findings | Interpretation |
| --- | --- | --- |
| Woman 1 | Primigravida, 5 cm dilated, contractions every 4 minutes, FHR 144 bpm, pain 8/10 | Active labor with expected pain; fetal heart rate is within normal range; pain relief is a comfort need, not immediately life-threatening |
| Woman 2 | 60 minutes postpartum; firm fundus at umbilicus; moderate lochia rubra; needs breastfeeding help | Expected postpartum findings; firm fundus indicates adequate contraction; breastfeeding support is a routine need |
| Woman 3 | 39 weeks, 3 cm dilated, crying and afraid | Psychosocial distress; requires emotional support and education, but no physiologic emergency is described |

Watch out! A soft, boggy fundus is never a normal postpartum finding. Even if the woman denies heavy bleeding, the nurse must palpate the fundus, massage it if boggy, and quantify blood loss by weighing or counting pads. Key point! Prioritization follows the ABCs and the principle that acute blood loss with a non-contracted uterus takes precedence over pain, routine postpartum care, and anxiety.

In BEmONC settings, the nurse’s first actions for suspected atony include uterine massage, administration of a uterotonic as per protocol, ensuring IV access, and calling for additional help while continuing to monitor vital signs and blood loss . The initial shock index and lactate level, when available, can help stratify severity and guide escalation, but the bedside recognition of a boggy uterus with active bleeding is the trigger for immediate action .References (research sources)

- [2]Recognition and Management of Postpartum Hemorrhage.Research articleMohamed TAEH, Chandraharan E. (2025) · DOI: 10.1097/fm9.0000000000000256

## 임상 시나리오

Postpartum Hemorrhage: First Assessment PriorityRecognizing uterine atony in a BEmONC setting
A soft, boggy fundus above the umbilicus with pad saturation in 15 minutes indicates uterine atony and active bleeding. The nurse must assess this woman first because postpartum hemorrhage can progress rapidly to hypovolemic shock.

A firm, contracted uterus compresses placental site vessels to limit bleeding. When the myometrium fails to contract, vessels remain open and blood loss becomes rapid and sustained. Fatigue may be an early sign of hypovolemia, not a reassuring finding.

CautionIn a BEmONC facility without surgical backup, the window for uterotonics, bimanual compression, and fluid resuscitation narrows quickly. Do not delay assessment based on the woman's statement that she only feels tired.

## 핵심 개념

- **Uterine atony** — Failure of the uterus to contract after birth, the leading cause of postpartum hemorrhage
- **Postpartum hemorrhage** — Blood loss over 500 mL after vaginal birth, potentially life-threatening without prompt treatment
- **Boggy fundus** — A soft, poorly contracted uterus on palpation, indicating loss of myometrial tone
- **BEmONC** — Basic Emergency Obstetric and Newborn Care, a facility level providing essential obstetric interventions
- **Lochia rubra** — Normal red vaginal discharge in the first days after birth

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