# Stage 2 — Analyze cues. Complete the analysis by selecting the option that best fits each blank. > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=617253&lang=en > language: en > subject: Pathophysiology > category: PA ## Question Stage 2 — Analyze cues. Complete the analysis by selecting the option that best fits each blank. A 32-year-old G3P3 client is 20 minutes after a vaginal birth that followed prolonged oxytocin-augmented labor. Quantified blood loss is 350 mL at birth plus 150 mL in the next 10 minutes and continuing. The fundus is soft, above the umbilicus, and deviated to the right; the bladder is palpable. The placenta appears complete and no laceration is visible. HR is 112/min and BP is 94/58 mm Hg. The most likely primary source of the bleeding is ::선택::a genital-tract laceration missed on inspectionretained placental fragmentsloss of uterine muscle tone. The position of the fundus is best explained by ::선택::a distended bladder displacing the uterusa broad-ligament hematoma pushing the uterus asidea partial inversion of the uterine fundus. The heart rate and blood pressure are best interpreted as ::선택::an expected response to pain and fatigue after long labora shock index above 1.0 consistent with significant blood lossan effect of treatment for gestational hypertension. If the client instead reported severe rectal pressure with a firm fundus and little visible bleeding, the nurse would suspect ::선택::a relapse of uterine atonya retained succenturiate placental lobea concealed vaginal or vulvar hematoma. ## Explanation A soft fundus with continuing bleeding after prolonged oxytocin-augmented labor points to atony; a palpable bladder displacing the uterus upward and to the right worsens contraction. A shock index of 112/94 (about 1.2) indicates significant hemorrhage even though the systolic pressure is still above 90. Pain or pressure with a firm uterus and little external bleeding would instead suggest a concealed hematoma. ## In-depth explanation Quick answer Loss of uterine tone; distended bladder; shock index above 1.0; concealed vaginal or vulvar hematoma. Why this is correct Using the four Ts (tone, trauma, tissue, thrombin), a soft, high fundus after a long oxytocin-exposed labor is a tone problem. Retained tissue is still possible when a placenta only appears complete, but it is not the most likely primary cause when a reversible atony cause (a full bladder) is present. The bladder explains the upward and lateral displacement. Heart rate divided by systolic pressure gives a shock index of about 1.2; values above 0.9 to 1.0 after birth predict the need for transfusion and escalation, which matters because pregnancy-related volume expansion delays hypotension. A firm uterus with pressure pain and little visible bleeding is the classic hematoma picture. Easy analogy or mental picture Think of the uterus as a fist that has to clench around open vessels: a tired fist after a long labor, pushed off-center by a full bladder, cannot clench. Memory hook "Boggy = tone; firm but bleeding = trauma; firm, painful, and dry = hematoma." NCLEX decision rule In postpartum bleeding, the fundal exam decides the source first: soft means atony until proven otherwise, and a shock index above 1.0 means significant blood loss regardless of the BP number. Why the other choices are wrong A missed laceration is tempting because inspection can be incomplete, but lacerations bleed with a firm uterus. Retained fragments can cause atony, yet the placenta appeared complete and a full bladder provides a more immediate explanation. A broad-ligament hematoma also displaces the uterus, but the bladder is palpable and bleeding is external. Uterine inversion produces a fundus that is absent or dimpled on palpation, not one that is high and deviated. Tachycardia from pain or fatigue, or low pressure from antihypertensives, are comforting explanations that delay response while bleeding continues. A succenturiate lobe or atony relapse would not produce a firm fundus with pressure pain. References 1ACOG Practice Bulletin No. 183: Postpartum HemorrhageUterine atony as the leading cause; evaluation of tone, trauma, tissue, and thrombin; bladder distention and early recognition 2CMQCC: OB Hemorrhage ToolkitQuantified blood loss, vital-sign triggers, and staged hemorrhage response ## Clinical scenario Case update The nurse integrates the bleeding pattern, uterine findings, source examination, and vital signs. ## Key concepts - **Shock index** — Heart rate divided by systolic blood pressure; a postpartum value above about 0.9 to 1.0 signals significant hemorrhage. - **Four Ts of postpartum hemorrhage** — Tone, trauma, tissue, and thrombin, the framework used to identify the bleeding source. - **Puerperal hematoma** — A concealed collection of blood in the vaginal or vulvar tissues that causes pain and pressure with little external bleeding. ## Related questions - [Stage 2 — Analyze cues. 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