Practice Question
A nurse is assessing a postpartum client who delivered vaginally 8 hr ago.
Answer Choices:
Correct Answer:
Uterine tone soft
Rationale:
✅ 1. Uterine tone soft
✔️ A soft or “boggy” uterus is a critical concern because it indicates uterine atony, the leading cause of postpartum hemorrhage (PPH).
✔️ Uterine atony prevents effective contraction of the uterus, allowing blood vessels at the placental site to remain open, leading to ongoing blood loss.
✔️ Immediate nursing intervention is required—this includes fundal massage, reassessment, and possibly notifying the provider if bleeding persists.
✔️ Even though vital signs appear stable, uterine atony may quickly progress to hypovolemic shock if uncorrected.
Clinical Priority: High risk for hemorrhage → must act immediately.
✅ 2. Large amount of lochia rubra
✔️ A large amount of lochia rubra, especially after initial moderate bleeding, may indicate excessive uterine bleeding, possibly due to uterine atony or retained placental fragments.
✔️ This change from earlier documentation (moderate → large) suggests a worsening condition.
✔️ Excess lochia paired with a boggy uterus points to an active bleeding episode requiring close observation and rapid intervention.
✔️ Consistent heavy bleeding postpartum is not normal and should never be dismissed as "expected" without thorough evaluation.
Clinical Priority: Abnormal blood loss → assess for cause and intervene.
✅ 3. Lateral deviation of the uterus
✔️ Lateral displacement of the uterus, typically to the right, usually indicates a distended bladder.
✔️ A distended bladder interferes with uterine contraction, contributing to uterine atony and increased bleeding.
✔️ Even though the nurse noted “able to void spontaneously” at 0700, this does not guarantee complete bladder emptying, especially if lochia increased and tone worsened.
✔️ Nursing action should include assisting the client to void, or catheterization if retention is suspected.
Clinical Priority: Bladder distention = impairs involution and increases bleeding risk.
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This question is from RN ATI Maternal&Newborn Care~2023 which contains 46 questions.
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Question Details
- Category: RN Nursing Exam(s)
- Subcategory: ATI Exam(s)
- Domain: RN ATI Maternal & Newborn Care
- Answer Choices: 7