A nurse is preparing to assess the uterine fundus of a client in the immediate post partum period. When the nurse assesses the fundus, she notes that the uterus feels soft and boggy. Which nursing intervention would be appropriate initially?

1. A

   Elevate the client's legs

2. B

   Massage the fundus until it is firm.

3. C

   Push on the uterus to assist in expressing clots

4. D

   Encourage the client to void

Appeared in: PGIMER Chandigarh NO - 2015

Explanation

• A soft and boggy uterus signifies uterine atony, meaning the uterine muscles are not contracting sufficiently to compress the blood vessels at the former placental site.
• The immediate priority is to stimulate uterine contraction to prevent or stop postpartum hemorrhage (PPH).
• Fundal massage is the most direct and effective initial intervention to make the uterus contract and become firm.
• This action involves placing one hand on the lower uterine segment for support while using the other hand to firmly massage the fundus in a circular motion.

Why Other Options Were Wrong

• Option A: Elevating the client's legs is an intervention for managing shock or hypotension. While it can improve venous return to the heart, it does not address the root cause of the bleeding, which is the non-contracting uterus.
• Option C: Pushing on a boggy (uncontracted) uterus is extremely dangerous as it can lead to uterine inversion, where the uterus turns inside out. This is a life-threatening emergency that can cause severe hemorrhage and shock.
• Option D: While a full bladder can displace the uterus and interfere with its ability to contract, emptying the bladder is not the first and most immediate action. The priority is to directly stimulate the uterus to contract via massage.

Related Visual

Clinical Relevance

• Nursing practice connection: Use the key finding related to Management of Uterine Atony in the Postpartum Period to guide bedside assessment, documentation, and the next nursing action.
• Uterine atony is the leading cause of postpartum hemorrhage (PPH), a major cause of maternal mortality worldwide. Prompt recognition and immediate fundal massage are critical life-saving skills for any nurse working in maternity care.
• The nurse's role is to act immediately by massaging the fundus, assessing the response, and then escalating care if the uterus does not become firm or if bleeding continues.
• Escalation includes notifying the provider, administering uterotonic medications as ordered (e.g., oxytocin, methylergonovine), ensuring IV access, and closely monitoring vital signs and blood loss.

How to Approach the Question

• First, identify the clinical finding in the question: the uterus is 'soft and boggy' in the immediate postpartum period.
• Recognize this as a critical sign of uterine atony, which leads to postpartum hemorrhage.
• The question asks for the 'initial' intervention. This signals a priority-setting question.
• Evaluate the options based on the ABCs (Airway, Breathing, Circulation) and the urgency of the problem. The immediate threat is hemorrhage (Circulation).
• Analyze which option directly addresses the cause of the hemorrhage. Fundal massage directly stimulates the uterus to contract and stop the bleeding.
• Rule out the other options as secondary or contraindicated actions. Pushing on a boggy uterus is dangerous. Emptying the bladder and elevating legs are important but not the first, most direct action.

Concept Tested & Keywords

• Concept Tested: Management of Uterine Atony in the Postpartum Period
• Stem keywords: uterine fundus, immediate post partum period, soft and boggy
• Lead-in keywords: appropriate initially
• Clinical cues: A soft and boggy uterus is the classic sign of uterine atony, which is the leading cause of postpartum hemorrhage.

Question ID

Q536SmcBw5ftVqcw7uPyOz

Copy ID

Reference Book

E6 Midwifery Obstetrics and Gynecology Nursing Sandeep Kaur pp. 1-4, 65-81