A nurse is caring for a client who is in a trial of labor for vaginal birth after cesarean (VBAC). The client reports a sudden tearing pain in their back and side that does not feel like a uterine contraction.
Which of the following findings indicates the client may be experiencing a uterine rupture?

Choice A rationale

Bladder distention upon palpation indicates urinary retention, not effective voiding. When the bladder remains distended, it signifies incomplete emptying, which can lead to urinary stasis and increased risk of urinary tract infections. Effective voiding requires coordinated detrusor muscle contraction and urethral sphincter relaxation, which is absent with distention.

Choice B rationale

A uterine fundus 2 cm above the umbilicus, especially in the postpartum period, suggests uterine atony and possible bladder distention. A full bladder can displace the uterus upward and to the side, preventing effective uterine contraction and involution, which is crucial for preventing postpartum hemorrhage. Normal fundal height should decrease daily.

Choice C rationale

Not feeling the urge to urinate could indicate nerve damage, overdistention with sensory nerve suppression, or a very low urine output. Normal bladder sensation is crucial for effective voiding. The absence of the urge may lead to prolonged bladder distention, increasing the risk of infection and bladder dysfunction, which hinders efficient emptying.

Choice D rationale

Urinating 30 mL/hr, while seemingly low, is a continuous output and suggests the client is able to empty their bladder, albeit slowly. Postpartum diuresis typically begins within 12 hours, with urine output of 100 to 250 mL/hr common. However, any consistent output, rather than retention, indicates some voiding effectiveness.

Choice A rationale

900 mL of urine output since birth (9 hours postpartum) translates to an average of 100 mL/hour. A normal urine output is typically 0.5 to 1 mL/kg/hour, which is usually greater than 30 mL/hour for adults. This indicates adequate renal perfusion and fluid balance rather than deficit.

Choice B rationale

A temperature of 37.6° C (99.6° F) is considered a low-grade fever. While it could be an early sign of infection, it is not a direct indicator of fluid volume deficit. Normal postpartum temperature may slightly increase due to dehydration or exertion during labor but usually remains below 38°C (100.4°F).

Choice C rationale

Reports of excessive sweating could be a compensatory mechanism for fever or a response to hormonal changes postpartum, but it is not a primary indicator of fluid volume deficit. In fact, excessive sweating can contribute to fluid loss, but it is not the most definitive sign.

Choice D rationale

A blood pressure of 80/55 mm Hg, particularly with a quantitative blood loss of 1200 mL, is a significant indicator of fluid volume deficit, specifically hypovolemic shock. Normal postpartum blood pressure is usually similar to pre-pregnancy levels (e.g., 90/60 to 120/80 mmHg). The low blood pressure reflects inadequate circulatory volume compromising tissue perfusion.