Ten minutes after placental delivery, the nurse notes a soft, boggy uterus and steady trickle of bright red blood.
What is the nurse's first action?

Choice A rationale

Uterine atony is a condition where the uterus fails to contract adequately after childbirth, leading to postpartum hemorrhage. This complication is not directly related to prolonged rupture of membranes or signs of infection, which are characterized by fever, foul-smelling amniotic fluid, and maternal tachycardia. Uterine atony is typically assessed by palpating a soft, boggy fundus, which is a sign of bleeding risk rather than ascending infection.

Choice B rationale

Placental abruption is the premature separation of the placenta from the uterine wall before delivery, usually causing painful vaginal bleeding and changes in fetal heart rate tracing. While serious, this condition is not indicated by the triad of prolonged rupture of membranes, maternal fever (100.8°F), and foul-smelling amniotic fluid, which strongly suggest an intra-amniotic infection.

Choice C rationale

Fetal acidosis, often determined by a fetal scalp pH < 7.20, indicates severe fetal distress resulting from interrupted oxygenation, potentially due to umbilical cord compression or placental insufficiency. Although infection can eventually lead to fetal distress, the primary clinical signs (fever, foul odor) point specifically to the infectious process of chorioamnionitis as the initial, most probable complication.

Choice D rationale

Chorioamnionitis is an intra-amniotic infection of the chorion, amnion, and amniotic fluid, typically caused by ascending bacteria following prolonged rupture of membranes (> 18 hours). Clinical findings of maternal fever (T > 100.4°F or 38.0°C), foul-smelling amniotic fluid, and maternal/fetal tachycardia are classic indicators of this severe obstetric complication.

Choice A rationale

While documentation is essential, it should follow the initial intervention to correct the displacement and pressure. Reassessing in one hour is inappropriate because a firm but displaced uterus, combined with a sensation of bladder pressure despite a recent small void (150 mL is generally considered a small volume in this context), strongly indicates a distended bladder is preventing the uterus from contracting effectively and remaining midline.

Choice B rationale

Administering intravenous pain medication does not address the underlying issue of uterine displacement and potential bladder distension. A full bladder is a priority concern as it significantly impedes uterine involution and increases the risk of excessive postpartum bleeding (hemorrhage). Pain relief is secondary to ensuring uterine stability and hemostasis.

Choice C rationale

Massaging a fundus that is already firm will not correct the issue of displacement caused by a full bladder and can cause unnecessary discomfort. The priority intervention is to empty the bladder to allow the uterus to return to the midline, contract efficiently, and reduce the risk of bleeding. The uterus is firm, suggesting good tone, but its position is compromised.

Choice D rationale

The most likely cause of a firm but displaced uterus (to the right) and the client's reported bladder pressure is urinary retention or a full bladder, even though she recently voided a small amount. An overdistended bladder prevents the uterus from contracting effectively and returning to the midline. Encouraging the client to void again, or assisting with catheterization if necessary, is the essential first step to allow the uterus to contract properly and centrally. —.