Day 1, 2350:

Client admitted to the postpartum unit.

Fundus firm at umbilicus.

Moderate amount of lochia rubra noted.

No concerns voiced by client.

 

Day 2,

0600:

Client resting in bed.

Reports pain as 5 on a scale of 0 to 10. Declines pain medication.

Fundus firm at umbilicus.

Moderate amount of lochia rubra noted.

Perineal pad changed.

Client assisted to the bathroom, voided 50 mL of urine.

Client performed incentive spirometer exercises.

0700:

Called to bedside by client.

Client reports needing help changing perineal pad.

Perineal pad saturated.

Fundus boggy and 2 finger breaths above the umbilicus deviated to the right side.

Client reports pain as 3 on a scale of 0 to 10. Client reports urge to urinate.

Ambulated client to the bathroom.

Client reports straining to empty bladder.

Client voided 50 mL of bloody urine.

Perineal pad changed.

Provider notified.

0715:

Straight catheter inserted per routine prescription.

Urinary output 700 mL of pink-tinged urine in catheter returned.

 

Which of the following conditions is the client most likely experiencing?

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.