A nurse is caring for a female client who is in the fourth stage of labor in the postpartum unit.

Complete the following sentence by using the list of options.
The nurse should first monitor the client’s

________

followed by the client’s

__________

.

Choice A rationale

The client's fundus is boggy and elevated above the umbilicus, deviating to the right, which indicates uterine atony. This, coupled with the saturated perineal pad and voiding of only 50 mL of urine initially, followed by 700 mL of pink-tinged urine after catheterization, suggests significant blood loss. These findings are classic signs of postpartum hemorrhage, which is often caused by uterine atony preventing effective uterine contraction and vessel compression. Normal postpartum fundal height should decrease daily.

Choice B rationale

Postpartum infection, such as puerperal sepsis, typically presents with fever, chills, uterine tenderness, and foul-smelling lochia. While the client is experiencing discomfort, there is no mention of fever or purulent discharge. The primary signs observed relate to excessive bleeding and uterine displacement, not infectious processes. A normal temperature range is 36.5°C to 37.5°C (97.7°F to 99.5°F).

Choice C rationale

Endometritis is an infection of the uterine lining, often occurring postpartum. Symptoms include fever, lower abdominal pain, uterine tenderness, and foul-smelling lochia. The client's symptoms of a boggy fundus, heavy bleeding, and fundal deviation are more indicative of a bleeding issue rather than an infection confined to the endometrium. White blood cell count would typically be elevated in infection, with a normal range being 4,500 to 11,000 cells/mm³.

Choice D rationale

A urinary tract infection (UTI) is characterized by dysuria, urgency, frequency, and sometimes hematuria. While the client reports an urge to urinate and voided a small amount, the primary and more concerning findings are related to the uterine status and excessive bleeding, which are not typical signs of a UTI. A urine culture would show bacterial growth in a UTI, with a normal urinalysis showing no or few bacteria.

Choice E rationale

Uterine inversion is a rare but severe complication where the uterus turns inside out, often presenting with sudden, severe pain, vaginal hemorrhage, and a mass protruding from the vagina. While hemorrhage is present, the description of the fundus being boggy and 2 finger breaths above the umbilicus, rather than inverted or prolapsed, makes uterine inversion less likely. The primary issue is uterine atony leading to blood loss.

Choice A rationale

A positive pregnancy test detects the presence of human chorionic gonadotropin (hCG) in urine or blood. While highly suggestive, it is classified as a probable sign because certain conditions other than pregnancy can elevate hCG levels, although these are rare, making it not definitively diagnostic.

Choice B rationale

Amenorrhea, the cessation of menstruation, is a common early indicator of pregnancy due to hormonal changes, specifically rising progesterone levels that inhibit follicular development and uterine shedding. However, various factors unrelated to pregnancy, such as stress or hormonal imbalances, can also cause amenorrhea, categorizing it as a presumptive sign.

Choice C rationale

Fetal heart sounds, when auscultated, are a definitive sign of pregnancy because they directly confirm the presence of a viable fetus. This auditory confirmation is unambiguous and cannot be attributed to any other condition, making it a positive sign of pregnancy.

Choice D rationale

Chadwick sign refers to the bluish-purple discoloration of the cervix, vagina, and labia due to increased vascularity and blood flow, typically observed around 6-8 weeks of gestation. While highly indicative of pregnancy, it is considered a probable sign because other conditions can also cause pelvic congestion, although less commonly.