# Stage 4 — Generate solutions. The client has ongoing atonic postpartum hemorrhage: QBL is 1,100 mL and rising, BP is 88/54, HR is 122, and the uterus relaxes again after initial measures. Which interventions are appropriate now? Select all that apply. > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=372472&lang=en > language: en > subject: Ante/Intra/Postpartum and Newborn Care > category: HPM ## Question Stage 4 — Generate solutions. The client has ongoing atonic postpartum hemorrhage: QBL is 1,100 mL and rising, BP is 88/54, HR is 122, and the uterus relaxes again after initial measures. Which interventions are appropriate now? Select all that apply. 1 Activate the PPH response; announce QBL and vital signs every 5 to 15 minutes, notify the obstetric clinician and blood bank, and prepare blood products 2 Continue bimanual uterine compression, treatment-dose oxytocin, and warmed isotonic fluid through two large-bore IV lines as prescribed 3 Wait for repeat hemoglobin and coagulation results before giving more medication or escalating care because current PT and platelet values exclude severe or evolving hemorrhage 4 Administer tranexamic acid 1 g IV over 10 minutes as soon as possible within 3 hours of birth; repeat 1 g once if bleeding continues after 30 minutes or restarts within 24 hours 5 Give an ordered second-line uterotonic after checking contraindications: avoid methylergonovine with hypertension and avoid carboprost with significant asthma or pulmonary disease 6 Continue evaluating the 4 Ts, inspect the genital tract and placenta, and prepare balloon tamponade, operating-room, or MTP escalation if bleeding and instability persist ## Explanation Five appropriate actions Correct care combines team activation and repeated QBL/vitals; bimanual compression, oxytocin, warmed IV fluid; early TXA; a contraindication-appropriate second-line uterotonic; and continued 4-T evaluation with balloon, OR, blood-product, or MTP readiness. A repeat hemoglobin must not delay treatment. ## In-depth explanation Step 1 — Deploy a bundle now The 2025 WHO guidance emphasizes immediate bundled care: uterine massage, oxytocic medication, TXA, IV fluid, genital-tract examination, and escalation when bleeding persists. CMQCC similarly uses team activation, frequent announced QBL/vitals, IV access, medication, laboratory, and blood-bank work in parallel. Step 2 — Give TXA early For clinically diagnosed PPH, WHO recommends TXA 1 g IV over 10 minutes within 3 hours of birth, with one repeat 1-g dose if bleeding continues after 30 minutes or restarts within 24 hours. Do not wait for uterotonics to fail completely. Step 3 — Match uterotonics to contraindications Methylergonovine is contraindicated with hypertension or toxemia. Carboprost is used cautiously or avoided with significant asthma or pulmonary disease according to protocol. The prescriber determines repeat carboprost dosing from the clinical course; the nurse verifies the order and contraindications. Step 4 — Escalate by trajectory Blood products, MTP, balloon tamponade, and operative management depend on continued bleeding, abnormal vital signs, product needs, and failure to control the source—not on waiting for one universal QBL or hemoglobin threshold. NCLEX rule In active PPH, choose simultaneous hemorrhage control, resuscitation, cause evaluation, and escalation readiness. ## Clinical scenario Scenario (Stage 4 — Generate solutions) Initial massage, bladder emptying, and oxytocin have not controlled rising hemorrhage with abnormal vital signs. Clinical judgment target Select the immediate multidisciplinary treatment bundle and reject laboratory or fixed-volume delays. ## Key concepts - **Tranexamic acid (TXA)** — An antifibrinolytic given early for clinically diagnosed PPH to reduce bleeding; it complements rather than replaces uterotonics and source control. - **Bimanual uterine compression** — Simultaneous internal and external uterine compression used as a temporizing hemorrhage-control maneuver. - **Massive transfusion protocol (MTP)** — A facility protocol that rapidly mobilizes balanced blood components when the pace and magnitude of bleeding require them. ## Related questions - [A nurse is providing preconception counseling to a 28-year-old woman planning a pregnancy …](https://mymerci.kr/pages/nclex_q.php?qn_id=364076&lang=en) - [A 28-year-old client at 6 weeks gestation, gravida 1 para 0, presents to the prenatal clin…](https://mymerci.kr/pages/nclex_q.php?qn_id=368130&lang=en) - [Stage 2 — Analyze cues. 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Always follow current clinical guidelines and your institution’s protocols._