# Stage 1 — Recognize cues. The nurse assesses a client on the postpartum unit 60 minutes after a vaginal birth. Review the assessment note. Highlight the findings that require immediate follow-up. > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=617309&lang=en > language: en > subject: Ante/Intra/Postpartum and Newborn Care > category: HPM ## Question Stage 1 — Recognize cues. The nurse assesses a client on the postpartum unit 60 minutes after a vaginal birth. Review the assessment note. Highlight the findings that require immediate follow-up. A 28-year-old G3P3 client gave birth vaginally 60 minutes ago to a 4.1-kg infant after oxytocin-augmented labor lasting 14 hours. She had a postpartum hemorrhage after her last birth. The placenta delivered intact. At the 15-minute check, the fundus was firm at the umbilicus and midline with QBL of 300 mL and moderate lochia. Since birth she has voided a small unmeasured amount only once. Admission BP was 124/78. Now: BP 92/58 and HR 116, RR 22, T 36.9 C, and SpO2 98 percent on room air. She is pale and reports new lightheadedness. The uterus is soft and boggy, with the fundus 2 cm above the umbilicus, deviated right. There is heavy lochia with clots; QBL now 700 mL. She rates cramping 4/10 during breastfeeding, and the perineum is intact with mild edema. ## Explanation Compared with the firm midline fundus and QBL of 300 mL at 15 minutes, the uterus is now soft and boggy, the fundus is 2 cm above the umbilicus and deviated right, and QBL has risen to 700 mL with clots, which signals active bleeding. BP 92/58 with HR 116 is a marked fall from the admission 124/78, and a single small void since birth suggests a distended bladder that can displace the uterus and worsen atony. The earlier firm fundus, intact placenta, afterpains, and mild perineal edema are expected findings, and the risk factors in the history are unselectable background. ## In-depth explanation Quick answer Highlight the single small void, BP 92/58 with HR 116, the soft boggy uterus, the high right-deviated fundus, and heavy lochia with QBL 700 mL. Why this is correct The trend is the cue: the fundus was firm and midline at 15 minutes and is now boggy, high, and deviated, while QBL has more than doubled. Hypotension and tachycardia compared with the admission 124/78 show the blood loss is already affecting circulation even though QBL is below 1,000 mL. Minimal voiding makes a full bladder likely, a correctable cause of displacement and atony. Easy analogy or mental picture A uterus after birth is a squeezed sponge; if it relaxes, it soaks up and leaks blood. A full bladder is a rock beside it that pushes it up and to the side and keeps it from clamping down. Memory hook Boggy, high, and off to the side: rub, void, and report the numbers. NCLEX decision rule Judge postpartum findings against the earlier check and the admission baseline. A change from firm to boggy, rising QBL, or falling BP with rising HR needs action now, regardless of an earlier reassuring assessment. Why the other choices are wrong The firm midline fundus and QBL 300 mL at 15 minutes were normal then, which is exactly why the current change matters; they are not current cues. An intact placenta lowers the likelihood of retained tissue but does not rule out atony. Cramping 4/10 during breastfeeding is expected afterpain from oxytocin release. Mild perineal edema with an intact perineum is expected after vaginal birth. The 4.1-kg infant, 14 hours of oxytocin augmentation, and prior PPH are unselectable history: they explain why atony was likely, but they are not signs of bleeding now. References 1ACOG Practice Bulletin No. 183: Postpartum HemorrhageUterine atony is the most common cause of PPH; tachycardia and hypotension may indicate substantial blood loss 2CMQCC Obstetric Hemorrhage ToolkitQuantitative blood loss, fundal assessment, and bladder emptying are core early hemorrhage-recognition steps ## Clinical scenario Scenario (Stage 1 — Recognize cues) One hour after a vaginal birth, the fundal findings, bleeding, and vital signs have changed from the 15-minute check and the admission baseline. Clinical judgment target Use the trend from the earlier check and the admission baseline to separate current bleeding and its causes from expected postpartum findings and background risk. ## Key concepts - **Uterine atony** — Failure of the postpartum myometrium to contract, which leaves placental-site vessels open and causes bleeding. - **Quantitative blood loss (QBL)** — Measured blood loss by weighing and collection rather than visual estimation. - **Fundal displacement** — A fundus above the umbilicus and deviated to one side, often from a distended bladder that interferes with contraction. ## 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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