Clinical context: Two hours after a vaginal birth, a client saturates a perineal pad in 12 minutes with continuous bright-red bleeding. The uterus is boggy and above the umbilicus. BP is 84/50 mm Hg and HR 126/min; the skin is pale and cool, and the client reports dizziness. The client had severe-range blood pressure earlier in labor and has active asthma that required rescue albuterol this week. The placenta was documented as intact, the bladder is nondistended, and no perineal swelling is seen. 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
Hemorrhage from uterine atony. Massage the fundus and increase the prescribed oxytocin infusion. Monitor fundal tone and quantitative blood loss.

Why this is correct
Uterine atony causes most postpartum hemorrhage: the relaxed myometrium cannot compress the placental-site vessels, so bleeding is brisk and the uterus feels soft and high. The documented intact placenta, empty bladder, and absent perineal swelling remove the other common causes. Oxytocin is the first-line uterotonic and is safe with hypertension and asthma, whereas methylergonovine can cause a hypertensive crisis and carboprost can trigger bronchospasm.

Easy analogy or mental picture
The uterus after birth is like a mesh of muscle fibers wrapped around open vessels. When the mesh tightens, the vessels are squeezed shut; when it goes slack, they pour. Massage and oxytocin tighten the mesh.

Memory hook
"Boggy = massage + oxytocin." Methergine skips high BP; Hemabate skips asthma.

NCLEX decision rule
For postpartum bleeding, find the cause with the 4 Ts (tone, trauma, tissue, thrombin), treat tone first when the uterus is boggy, and check each uterotonic against the client's contraindications before giving it.

Why the other choices are wrong
A laceration bleeds with a firm uterus, and retained tissue requires an incomplete placenta; here the uterus is boggy and the placenta intact, so hematoma checks do not track the problem. A full bladder can push the uterus up, but this bladder is nondistended, so catheterization would not treat the cause. Methylergonovine and carboprost are real second-line uterotonics, which makes them tempting, but severe-range blood pressure and active asthma contraindicate them; peak flow would only matter if carboprost had been given. Deep tendon reflexes track magnesium therapy for preeclampsia, not hemorrhage.