A nurse is checking the fundus of a postpartum woman and notes that the uterus is soft and spongy. Which nursing action appropriate initially?

1. A

   Notify the physician

2. B

   Encourage the mother to ambulate

3. C

   Massage the fundus gently until it is firm

4. D

   Document fundal position, consistency and height

Appeared in: DHS 2018 shift 1st

Explanation

• A soft and spongy uterus is described as 'boggy,' which is the classic sign of uterine atony.
• Uterine atony is the failure of the uterus to contract sufficiently after childbirth and is the most common cause of postpartum hemorrhage (PPH).
• The immediate priority is to stimulate uterine contraction to compress the blood vessels at the placental site and control bleeding.
• Gentle fundal massage is the most effective and appropriate initial nursing intervention to make the uterus firm, thereby preventing or managing PPH.

Why Other Options Were Wrong

• Option A: This is not the initial action. The nurse must intervene first to attempt to stabilize the patient. Delaying intervention to notify the physician can lead to significant blood loss.
• Option B: This action is contraindicated. Ambulation can increase blood flow and poses a significant safety risk, as the woman may be hypotensive and at risk for fainting (syncope).
• Option D: Intervention takes priority over documentation in an emergency or potentially life-threatening situation. The nurse must act first to correct the problem.

Related Visual

Clinical Relevance

• Nursing practice connection: Use the key finding related to Initial nursing management of uterine atony in the postpartum period to guide bedside assessment, documentation, and the next nursing action.
• Prompt recognition and management of a boggy uterus are critical nursing skills to prevent postpartum hemorrhage (PPH), a leading cause of maternal mortality worldwide.
• Fundal massage is an independent nursing intervention that can be initiated immediately without a physician's order, empowering nurses to act quickly in an emergency.
• What if? - If the uterus remains boggy despite massage and bleeding continues, the nurse's next actions are to call for help, notify the provider, ensure patent IV access for fluids and blood products, and prepare to administer uterotonic drugs (e.g., oxytocin, methylergonovine, carboprost) as ordered.

How to Approach the Question

• This is a clinical priority question, asking for the 'initial' action.
• First, identify the clinical finding: a 'soft and spongy' fundus. Translate this to its clinical term: a 'boggy' uterus.
• Next, recognize the immediate danger associated with this finding: uterine atony, which leads to postpartum hemorrhage (PPH).
• Apply the nursing process principle: Assessment (finding the boggy uterus) leads to immediate Intervention to address the life-threatening risk.
• Evaluate the options based on priority. Which action directly and immediately addresses the problem of an uncontracted uterus? Fundal massage is the direct physical intervention.
• Eliminate the other options: Notifying the physician and documenting are secondary actions (Notify/Document after Intervening). Encouraging ambulation is unsafe and contraindicated.

Concept Tested & Keywords

• Concept Tested: Initial nursing management of uterine atony in the postpartum period.
• Stem keywords: postpartum, fundus, soft and spongy, nursing action
• Lead-in keywords: initially
• Clinical cues: The finding of a 'soft and spongy' uterus is a critical cue for uterine atony, a medical emergency.
• Negative lead-in flag: false

Question ID

QVmm9G12gy4hgqkfW01BeU

Copy ID

Reference Book

E6 Midwifery Obstetrics and Gynecology Nursing Sandeep Kaur pp. 1-4, 4-9