The nurse assesses a boggy uterus with the fundus above the umbilicus and deviated to the side. The nurse should next assess:
Blood pressure
Amount of lochia
Fulness of the bladder
Level of pain
The Correct Answer is C
Fullness of the bladder. A boggy uterus with the fundus above the umbilicus and deviated to the side indicates that the uterus is not contracting properly and may be displaced by a full bladder. A full bladder can interfere with uterine involution and increase the risk of postpartum hemorrhage. The nurse should assess the bladder and assist the patient to empty it if needed.
Choice A. Blood pressure is not the next assessment because it is not related to the position and tone of the uterus. Blood pressure may be affected by blood loss, but it is not a priority in this situation.
Choice B. Amount of lochia is not the next assessment because it is not related to the position and tone of the uterus. Lochia may be increased or decreased depending on the uterine contraction, but it is not a priority in this situation.
Choice D. Level of pain is not the next assessment because it is not related to the position and tone of the uterus. Pain may be present due to uterine cramping or other factors, but it is not a priority in this situation.
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Correct Answer is D
Explanation
Precipitous birth
This is because precipitous birth, which is defined as a labor that lasts less than three hours from the onset of contractions to delivery, is a risk factor for postpartum hemorrhage. This is because the uterus may not contract well after a rapid delivery, leading to uterine atony and bleeding. Other risk factors for postpartum hemorrhage include uterine overdistension, oxytocin use, placental abruption, placenta previa, infection, coagulation disorders, and previous history of postpartum hemorrhage.
Choice A is not correct because gestational hypertension is not a risk factor for postpartum hemorrhage. It is a condition that causes high blood pressure during pregnancy and can lead to complications such as preeclampsia, eclampsia, and placental abruption³.
Choice B is not correct because small for gestational age newborn is not a risk factor for postpartum hemorrhage. It is a condition that indicates that the baby's growth was restricted in the womb and weighs less than 90% of other babies of the same gestational age. It can be caused by maternal factors, placental factors, or fetal factors⁴.
Choice C is not correct because a two-vessel umbilical cord is not a risk factor for postpartum hemorrhage. It is a condition that occurs when the umbilical cord has only one artery and one vein instead of the normal two arteries and one vein. It can be associated with congenital anomalies, intrauterine growth restriction, and stillbirth.
Correct Answer is A
Explanation
Massage the fundus. This is because massaging the fundus (the upper part of the uterus) can help the uterus contract and prevent excessive bleeding after delivery. A soft, boggy uterus indicates uterine atony, which is a failure of the uterus to contract sufficiently after childbirth.
Uterine atony is the most common cause of postpartum hemorrhage, which can be life-threatening if not treated promptly¹².
Choice B is not correct because initiating measures that encourage voiding is not the appropriate intervention for a soft, boggy uterus. A full bladder can interfere with uterine contractions and cause bleeding, so it is important to empty the bladder after delivery. However, this should be done after massaging the fundus.
Choice C is not correct because positioning the patient flat is not the appropriate intervention for a soft, boggy uterus. Positioning the patient flat can increase blood loss and reduce venous return. The patient should be positioned with the head slightly elevated and the legs flexed to improve blood circulation and prevent shock³.
Choice D is not correct because notifying the doctor is not the first intervention for a soft, boggy uterus. Notifying the doctor is important if bleeding persists or worsens despite massaging the fundus. The doctor may order medications or other treatments to stop the bleeding and prevent complications¹.
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