A patient is in the immediate postpartum period after having delivered 9 pound. 14-ounce baby (4480 grams). iS 6. The patient is gravida 6, para 5. The nurse notices some new blood stains on the top sheets and discovers the patient lying in a pool of blood. The fundus is located above the umbilicus and is boggy. The bladder is not palpable. What would be the nurse's priority action?

Massage the fundus

Take the patient's blood pressure

Start an IV

Have the patient empty her bladder

Answer and Explanation

The Correct Answer is A

A) Massage the fundus:
The first priority in this situation is to massage the fundus to help control potential postpartum hemorrhage caused by uterine atony. A boggy fundus (soft and not firm) suggests that the uterus is not contracting effectively, which can lead to excessive bleeding. Massaging the fundus stimulates uterine contractions, which can help reduce bleeding by compressing the blood vessels that were supplying the placenta. The nurse should begin with this intervention immediately to address the most likely cause of the bleeding.

B) Take the patient's blood pressure:
While vital signs such as blood pressure are important for assessing shock or ongoing hemorrhage, massaging the fundus takes priority in this scenario to directly address the cause of the bleeding. Taking the blood pressure is not the most immediate intervention for this specific situation because the primary issue here is uterine atony, not hemodynamic instability (although it will need to be assessed shortly thereafter).

C) Start an IV:
Starting an IV may be important if there is significant blood loss, but it is not the first priority in this scenario. The nurse should first focus on stabilizing the uterus by massaging the fundus. IV access will become more critical if the bleeding is not controlled after the fundus is massaged and other interventions are required.

D) Have the patient empty her bladder:
While a full bladder can sometimes displace the uterus and cause it to be less effective at contracting, this is a secondary concern. The first priority is to address the uterine atony by massaging the fundus. Once the fundus is firm and bleeding is under control, the nurse can then consider having the patient empty her bladder to ensure it isn't interfering with the uterus' ability to contract.

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Correct Answer is ["A","B","C","E"]

Explanation

A) The urethra, bladder, and urinary meatus are edematous:
Postpartum women often experience edema in the urethra, bladder, and urinary meatus due to the pressure exerted during delivery. This swelling can make it difficult for the woman to feel the urge to urinate, even when her bladder is full. Encouraging her to urinate every 2 hours helps prevent overdistension of the bladder, which can lead to urinary retention and other complications.

B) She has decreased sensitivity to fluid pressures after a vaginal birth:
After childbirth, especially a vaginal birth, the pelvic floor and surrounding tissues can be numb or less sensitive due to trauma, swelling, and the effects of anesthesia. This decreased sensitivity makes it harder for the woman to sense when she needs to urinate. Encouraging regular voiding even without the urge helps to prevent urinary retention, which is common in the immediate postpartum period.

C) At 12 hours postpartum, she will begin diuresing:
Diuresis, the process of excreting excess fluid retained during pregnancy, typically begins within 12 hours postpartum. This increased urine output can make it even more important for the mother to void regularly to prevent urinary retention. If the bladder is not emptied regularly, it can lead to discomfort and increase the risk of complications like bladder distention or infection.

D) There is no cause for concern as long as the patient urinates once per shift:
This is not true. A postpartum woman should void more frequently than once per shift (which is about every 8 hours). Urinating only once every shift can lead to urinary retention, bladder overdistension, and possible infection. The recommendation to urinate every 2 hours helps ensure proper bladder emptying and reduces the risk of complications.

E) A full bladder can lead to postpartum hemorrhage:
A full bladder can indeed contribute to postpartum hemorrhage (PPH). An overdistended bladder can displace the uterus, preventing it from contracting effectively after delivery. This can increase the risk of excessive bleeding. Regular voiding helps prevent bladder distention and supports uterine contraction, thereby reducing the risk of hemorrhage.

A. The fundus is palpable two fingerbreadths above the umbilicus. B. The fundus is palpable at the level of the umbilicus. C. The fundus is palpable one fingerbreadth below the umbilicus. D. The fundus is palpable two fingerbreadths below the umbilicus.

Correct Answer is D

Explanation

A. The fundus is palpable two fingerbreadths above the umbilicus:
While it is higher than expected, this finding may occur if the uterus is still contracting and involuting, as it can sometimes be positioned slightly higher. However, this is not necessarily a cause for concern, and further assessment would depend on other factors like bleeding or discomfort. If the fundus is firm and contractions are present, this finding may still be within a normal range.

B. The fundus is palpable at the level of the umbilicus:
At 12 hours postpartum, the fundus should generally be at the level of the umbilicus. This is an expected finding in the immediate postpartum period as the uterus is beginning to involute. No further action is required unless other complications, like excessive bleeding or signs of infection, are present.

C. The fundus is palpable one fingerbreadth below the umbilicus:
This is another typical finding 12 hours after birth. By this time, the uterus should be involuting and should be slightly below the umbilicus. A slight descent of the fundus is normal as the uterus shrinks and contracts. As long as the fundus is firm and there are no other concerning signs, this is a normal finding.

D. The fundus is palpable two fingerbreadths below the umbilicus:
A fundus palpated two fingerbreadths below the umbilicus 12 hours postpartum suggests that involution may not be progressing as expected. It could indicate uterine atony, where the uterus is not contracting effectively, increasing the risk for postpartum hemorrhage. This requires further assessment to rule out complications such as retained placental fragments or excessive bleeding. Immediate action, including uterine massage or other interventions, may be needed.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","B","C","E"]

Explanation

Which finding 12 hours after birth requires further assessment?

Correct Answer is D

Explanation

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