Twelve minutes after a vaginal birth, a client continues to bleed. Prophylactic oxytocin was given after the birth, and the placenta was inspected and found intact. Quantified blood loss is 700 mL and rising. The client is pale with heart rate 124/min and blood pressure 88/50 mm Hg. The uterus is boggy, 2 cm above the umbilicus, and displaced to the right; it firms temporarily and the flow slows during massage, then relaxes again. The client has not voided since before the birth. The perineum has a small first-degree laceration that is not actively bleeding. Complete the diagram by selecting the condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Quick answer
Uterine atony; massage the fundus and empty the bladder by straight catheterization; monitor fundal tone and position and cumulative quantified blood loss.

Why this is correct
Bleeding that slows when the uterus firms under massage comes from the placental site, which means tone is the problem. The fundus is above the umbilicus and pushed to the right, and the client has not voided, so a full bladder is keeping the uterus from contracting. Massage and bladder emptying restore contraction; fundal firmness, return to midline, and the quantified blood-loss total show success.

Easy analogy or mental picture
The uterus is a sponge that has to be squeezed shut over open vessels. A full bladder is a book wedged under the sponge, so it cannot close no matter how hard you press.

Memory hook
Boggy + shifted = rub and drain (massage the fundus, empty the bladder).

NCLEX decision rule
When postpartum bleeding responds to fundal massage and the uterus is displaced, treat tone first and empty the bladder; look for trauma or tissue only when the uterus is firm and bleeding continues.

Why the other choices are wrong
A laceration bleeds despite a firm uterus; here bleeding slows with massage and the small first-degree tear is not bleeding, so repair and perineal pain do not track the hemorrhage. Retained tissue is unlikely with an intact placenta, so manual removal is not indicated, and lochia odor tracks later infection. Uterine inversion causes a missing or dimpled fundus, not a high displaced one. Trendelenburg positioning is an outdated shock measure that impairs ventilation and does not treat the cause. Temperature reflects infection, not bleeding control.