A client gives birth within an hour of arriving at the labor and delivery unit and delivers the placenta 5 minutes later. During assessment, the nurse notes that the uterus is midline and boggy. Which action should the nurse take first?

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11ecbb05_cc00_aee5_b433_15d35992102a_MD0009_00 After delivery of the placenta, the uterus begins the process of involution. The uterus should be firmly contracted, midline, and at or slightly below the umbilicus. A boggy uterus indicates uterine atony, a state in which the uterus fails to contract adequately and compress vessels at the placental detachment site. This may lead to excessive blood loss and clots. The initial nursing action for uterine atony with a midline fundus is fundal massage, which stimulates contraction of the uterine smooth muscle (Option D). If the uterus becomes firm with massage, the nurse should continue to monitor uterine tone, position, and lochia at least every 15 minutes in the initial hour after birth. (Option A) The nurse should monitor lochia frequently in the immediate postpartum period, especially underneath the client where blood can pool and go undetected. However, fundal massage is most important because uncorrected uterine atony will eventually result in excessive blood loss. (Option B) Uterotonics (eg, oxytocin, methylergonovine) stimulate the uterus to contract. If the uterus fails to contract despite massage, further administration of uterotonics is indicated. (Option C) Monitoring blood pressure and pulse are important interventions for postpartum clients, especially those at risk for excessive blood loss. This intervention may be delayed until after fundal massage to reduce further blood loss. Educational objective: After placenta delivery, the fundus should be firm, midline, and at or slightly below the umbilicus. The initial nursing action to correct uterine atony with a midline, boggy uterus is fundal massage.

A Client Gives Birth Within an Hour of Arriving at the Labor