# A nurse is caring for a postpartum patient who has saturated 2 perineal pads in 30 minutes. Fundus is boggy and displaced upward. Which nursing actions are appropriate using the 4 Ts framework? Select all that apply. > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=374930&lang=en > language: en > subject: Basic Care and Comfort > category: BCC ## Question A nurse is caring for a postpartum patient who has saturated 2 perineal pads in 30 minutes. Fundus is boggy and displaced upward. Which nursing actions are appropriate using the 4 Ts framework? Select all that apply. 1 Delay fundal massage and bladder assessment for 30 minutes to see if the uterus firms on its own, because excessive manipulation can cause further bleeding. 2 Thrombin (coagulopathy): assess for DIC signs, especially in pre-eclampsia, abruption, or septic shock; obtain coagulation panel. 3 Trauma (lacerations or hematoma): inspect the perineum, vagina, and cervix for tears or visible hematoma; bright red bleeding with firm fundus suggests trauma. 4 Tissue (retained placenta): inspect the placenta after delivery for completeness; suspect retained products if PPH continues despite contracted uterus. 5 Tone (uterine atony — most common cause): perform fundal massage immediately and assist with bladder emptying since a full bladder displaces the uterus and worsens atony. ## Explanation 4 Ts of postpartum hemorrhage: TONE (uterine atony — 70-80% of PPH; massage, oxytocin, methylergonovine, carboprost, misoprostol; check bladder), TISSUE (retained placenta), TRAUMA (lacerations, hematoma), THROMBIN (coagulopathy — DIC). Choice 1 is dangerous — PPH is a leading cause of maternal mortality; immediate action and provider notification are required, not waiting. ## In-depth explanation Tone is the FIRST T to evaluate because uterine atony causes 70-80% of PPH. The boggy fundus with displaced position is classic atony often from full bladder. Memorize the uterotonic ladder: oxytocin → methylergonovine (avoid in HTN) → carboprost (avoid in asthma) → misoprostol → tranexamic acid. The "wait and see" trap is fatal in PPH. ## Clinical scenario **Postpartum patient with saturated 2 perineal pads in 30 minutes** and **boggy upward-displaced fundus**. The nurse uses the **4 Ts framework** (Tone, Tissue, Trauma, Thrombin) to evaluate postpartum hemorrhage etiology. ## Key concepts - **4 Ts of PPH** — Tone, Tissue, Trauma, Thrombin — systematic evaluation framework for postpartum hemorrhage etiology. - **Uterine atony** — Boggy uterus failing to contract; 70-80% of PPH; treat with massage, bladder emptying, oxytocin, methylergonovine, carboprost. - **Methylergonovine / carboprost cautions** — Methylergonovine contraindicated in HTN/preeclampsia; carboprost (Hemabate) contraindicated in asthma. ## Related questions - [A patient with cirrhosis and grade 2 hepatic encephalopathy has been started on lactulose.…](https://mymerci.kr/pages/nclex_q.php?qn_id=372852&lang=en) - [A 78-year-old with end-stage pancreatic cancer is admitted to the medical ward. After revi…](https://mymerci.kr/pages/nclex_q.php?qn_id=372916&lang=en) - [A patient is in the active dying phase from end-stage heart failure. Family members are at…](https://mymerci.kr/pages/nclex_q.php?qn_id=373259&lang=en) - [A nurse is caring for an immobile, malnourished older adult at high risk for pressure inju…](https://mymerci.kr/pages/nclex_q.php?qn_id=373515&lang=en) - [A patient is post-op day 0 from a transurethral resection of the prostate (TURP) with a th…](https://mymerci.kr/pages/nclex_q.php?qn_id=374201&lang=en) - [A 6-year-old is admitted with newly diagnosed nephrotic syndrome: proteinuria 4+, serum al…](https://mymerci.kr/pages/nclex_q.php?qn_id=374922&lang=en) - [A nurse is implementing trauma-informed care for a client with a history of intimate partn…](https://mymerci.kr/pages/nclex_q.php?qn_id=374978&lang=en) - [A nurse is supporting a family meeting where the medical team is discussing transition to …](https://mymerci.kr/pages/nclex_q.php?qn_id=374987&lang=en) ## Read in another language - [en](https://mymerci.kr/pages/nclex_q.php?qn_id=374930&lang=en) - [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=374930&lang=ko) - [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=374930&lang=ja) - [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=374930&lang=zh-tw) - [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=374930&lang=vi) --- More free questions: [NCLEX-RN Practice](https://mymerci.kr/pages/nclex_bank.php?lang=en) _For study reference only. Always follow current clinical guidelines and your institution’s protocols._