# Stage 1 — Recognize cues. A 32-year-old G3P3 client with gestational hypertension and asthma is 20 minutes after a vaginal birth that followed prolonged labor with oxytocin augmentation. HR is 112/min. Click the findings that require immediate follow-up.

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## Question

Stage 1 — Recognize cues. A 32-year-old G3P3 client with gestational hypertension and asthma is 20 minutes after a vaginal birth that followed prolonged labor with oxytocin augmentation. HR is 112/min. Click the findings that require immediate follow-up.

| Assessment | Finding |
| --- | --- |
| Chills | Shaking chills 5 minutes after birth, now easing |
| Fundus | Soft, 2 cm above the umbilicus, deviated to the right |
| Placenta | Delivered at 12 minutes; membranes and cotyledons appear complete |
| Blood pressure | 94/58 mm Hg; 148/92 mm Hg during labor |
| Perineum | Mild edema; no laceration visible |
| Measured blood loss | 350 mL at birth, then 150 mL in the next 10 minutes |
| Respiratory | SpO2 98% on room air; faint end-expiratory wheeze, as at her visit this month |
| Bladder | Palpable above the symphysis; last voided before pushing |
| Pain | Cramping afterpains rated 5/10 during breastfeeding |

## Explanation

The soft, high, displaced fundus, the palpable bladder, the rate of measured loss (150 mL in 10 minutes on top of 350 mL), and a blood pressure that has fallen from 148/92 to 94/58 mm Hg in a client with gestational hypertension require immediate action. Postpartum chills, afterpains in a multipara, perineal edema, a baseline asthma wheeze with normal saturation, and an apparently complete placenta are expected or chronic findings.

## In-depth explanation

Quick answer
Fundus, blood pressure, measured blood loss, and bladder.

Why this is correct
The fundus should be firm and midline; a soft fundus deviated by a full bladder is the mechanism of ongoing bleeding. The measured loss matters most as a rate: 150 mL in 10 minutes is continuing hemorrhage even though the total has only just reached 500 mL. A BP of 94/58 mm Hg might look acceptable for a healthy postpartum client, but this client was hypertensive during labor, so a fall of more than 50 mm Hg systolic with HR 112/min signals hypovolemia. The bladder must be emptied because it prevents uterine contraction.

Easy analogy or mental picture
Read the table like a before-and-after photo: the numbers that changed the most from this client's own earlier self are the ones bleeding is writing.

Memory hook
"Judge the BP against her labor BP, judge the blood loss by its speed."

NCLEX decision rule
In postpartum assessment, compare vital signs with the client's own baseline and treat an ongoing bleeding rate with a soft fundus as hemorrhage before totals reach a threshold.

Why the other choices are wrong
Postpartum chills are a common, self-limited reaction and are easing. Afterpains are expected in a multiparous breastfeeding client and actually indicate uterine contraction. Mild perineal edema without a laceration is expected after vaginal birth. The wheeze matches her recent baseline with normal saturation; it matters for drug selection later but is not the immediate problem. An apparently complete placenta lowers, but does not eliminate, suspicion of retained tissue and does not itself require action.

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
Immediate postpartum assessment — bleeding continues after a vaginal birth.

## Key concepts

- **Uterine atony** — Failure of the uterine muscle to contract after birth, the most common cause of postpartum hemorrhage.
- **Quantified blood loss** — Objective measurement of blood loss by weighing and collecting, more accurate than visual estimation.
- **Afterpains** — Cramping from uterine contractions after birth, more intense in multiparas and during breastfeeding.

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