The nurse is assessing a gravid client. Which finding is of greatest concern in planning care for this client?

Rationale:

• Fundus massaged until firm and at umbilicus: Massaging the fundus until it is firm at the umbilicus indicates that uterine tone is restored, reducing the risk of postpartum hemorrhage. This is a positive sign that the uterus is contracting effectively and bleeding is controlled.
• Multiple large clots were expelled: The expulsion of multiple large clots suggests the possibility of retained blood or tissue in the uterus, which could interfere with uterine contraction and lead to continued bleeding. This increases the risk of hypovolemia.
• Blood pressure of 110/80 mm Hg, heart rate of 66 beats/minute, oxygen saturation at 98% on room air: These vital signs suggest the patient is stable, with normal blood pressure, heart rate, and oxygen saturation, indicating good circulation and oxygenation. This reflects improvement in her overall condition, decreasing the likelihood of hypovolemia.
• Fundus remains firm with slight lochia noted on pad: A firm fundus is a good sign that uterine contractions are adequate. Slight lochia is expected in the early postpartum period, and the absence of heavy bleeding suggests improved uterine tone and no active hemorrhage.
• Straight catheter produced 500 mL clear yellow urine: A 500 mL urine output indicates that the bladder is functioning well, which may also help the uterus to contract more effectively. Proper bladder function reduces the risk of uterine displacement.

• Total blood loss of 800 mL: Blood loss of 800 mL is above the typical range for a vaginal delivery (300-500 mL), which places the patient at increased risk for hypovolemia. This amount of blood loss requires close monitoring and intervention.
• 200 mL blood loss: Although 200 mL is not extreme, ongoing blood loss that exceeds the expected range for the first few hours postpartum can still place the patient at risk for hypovolemia.

Rationale for Correct Choices:

• 36-year-old client who is gravida 5, para 5 (G5P5): The client is a multipara, which increases the risk of uterine atony due to difficulty with uterine contractions or postpartum hemorrhage as a result of overstretched uterine muscles.
• Transferred to the postpartum unit 1 hour after delivery of a 9 lb. 1 oz (4.1 kg) female: Macrosomia increases the likelihood of trauma during delivery, including lacerations and uterine atony increasing the risk for postpartum hemorrhage.
• In labor for 25 hours: Prolonged labor increases the risk of uterine atony, where the uterus struggles to contract after delivery. This can lead to an increased risk of postpartum hemorrhage as the uterus fails to close off blood vessels effectively.
• Forceps were used to assist with the delivery: Forceps-assisted deliveries can cause trauma to the birth canal, cervix, or perineum, leading to increased bleeding. This traumatic delivery can also contribute to uterine atony, raising the risk of postpartum hemorrhage.
• 4th degree laceration: A 4th degree laceration involves extensive damage to the perineum and anal sphincter, increasing bleeding risk. This severe injury requires surgical repair and is a known risk factor for postpartum hemorrhage due to the size and depth of the tear.
• Estimated blood loss was 600 mL after delivery: Blood loss of 600 mL after delivery, although within the normal range for some vaginal deliveries, is considered a moderate risk factor. It may indicate ongoing bleeding or inadequate uterine contraction, both contributing to postpartum hemorrhage risk.
• Macrosomic baby (9 lb 1 oz): A larger-than-normal baby (macrosomia) increases the likelihood of a difficult delivery, trauma to the birth canal, and uterine atony. These factors, combined with a prolonged labor, raise the risk of postpartum hemorrhage.

Rationale for Incorrect Choices:

• Epidural anesthesia: The use of epidural anesthesia provides pain relief but does not directly increase the risk of postpartum hemorrhage. While epidurals may delay mobilization, they do not interfere with uterine tone or bleeding.
• Vital signs were stable: Stable vital signs, including normal blood pressure, respiratory rate, and heart rate, indicate that the client is not in acute distress or hemorrhaging severely at this time.