A nurse is caring for a female client who is gravida 1 para 0 at 32 weeks of gestation in the antepartum unit.

Complete the following sentence by using the list of options.
The nurse should identify that

____________

and

___________

are findings that require follow-up.

Based on the 0715 assessment findings, the nurse identifies that the client is at greatest risk for developing postpartum hemorrhage and urinary tract infection.

Rationale for correct answers
Postpartum hemorrhage risk is indicated by a boggy fundus located 2 fingerbreadths above the umbilicus and deviated to the right, signifying uterine atony and bladder distention. Uterine atony causes inadequate contraction, increasing bleeding risk. Normal fundal position is firm, midline, at or below the umbilicus. The client’s saturated perineal pad confirms excessive bleeding. Urinary tract infection risk is suggested by urinary retention signs (urge to urinate but only voiding 50 mL) and straining, increasing bacterial colonization risk. Blood-tinged urine further supports urinary tract irritation or infection. Normal urine output in adults is approximately 0.5 mL/kg/hr; this client’s low output suggests retention.

Rationale for incorrect answers
Postpartum infection (B) and endometritis (C) are possible but less immediately likely; WBC is normal at 7,500/mm³ and temperature is only mildly elevated (37.7°C). Uterine inversion (D) is a rare, acute emergency with a prolapsed uterus, not described here. Endometritis (B) typically presents with fever, uterine tenderness, and elevated WBC, absent here.

Rationale for incorrect answers
Postpartum infection (A) and endometritis (B) again are unlikely given stable WBC and low-grade temperature. Uterine inversion (D) does not correlate with the clinical presentation of a boggy, displaced fundus and urinary retention. The urinary tract infection (C) is most consistent with symptoms of retention, pain, and bloody urine.

Take home points

• Boggy, displaced fundus with heavy bleeding signals uterine atony and postpartum hemorrhage risk.
• Urinary retention increases risk for urinary tract infection post-cesarean birth.
• Mild temperature elevation and normal WBC do not confirm infection but warrant monitoring.
• Differentiating uterine atony from uterine inversion and infection is critical for timely intervention.

Placement of an internal fetal spiral electrode is contraindicated because it requires ruptured membranes and no active vaginal bleeding. In cases of antepartum bleeding, especially without rupture of membranes, it increases infection risk and fetal injury.

Laboratory testing (CBC, blood type, Rh factor, coagulation studies) is anticipated to evaluate maternal blood loss, anemia, blood type compatibility, and coagulation status. These are essential for managing bleeding risk and potential transfusions.

IV fluids are anticipated to maintain maternal hemodynamic stability and manage possible blood loss, preventing hypovolemia and hypotension.

Abdominal ultrasound is anticipated for placental localization, fetal wellbeing assessment, and to differentiate causes of bleeding (placenta previa vs. abruption).

Betamethasone administration is anticipated at 30 weeks to accelerate fetal lung maturity in case of preterm delivery.

Continuous fetal heart rate (FHR) monitoring is essential to assess fetal status and detect hypoxia or distress promptly.

Digital cervical exam is contraindicated due to risk of exacerbating bleeding and infection in the presence of unknown placental position or bleeding source.