# Stage 3 — Prioritize hypotheses. The 32-year-old G3P3 client with gestational hypertension and asthma is 20 minutes after a vaginal birth that followed prolonged oxytocin-augmented labor. Quantified blood loss was 350 mL at birth plus 150 mL in the next 10 minutes, and bleeding continues. The fundus is soft, 2 cm above the umbilicus, and deviated to the right; the bladder is palpable above the symphysis, and the client last voided before pushing. The placenta appeared complete, and no laceration is visible. The client reports dizziness and no rectal pressure. HR 112/min, BP 94/58 mm Hg (148/92 during labor), capillary refill 3 seconds, SpO2 98% with a faint end-expiratory wheeze noted at prenatal visits. Complete the diagram by selecting the condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

> source: MyMerci (mymerci.kr)  
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> language: en  
> subject: Establishing Priorities  
> category: MOC

## Question

Stage 3 — Prioritize hypotheses. The 32-year-old G3P3 client with gestational hypertension and asthma is 20 minutes after a vaginal birth that followed prolonged oxytocin-augmented labor. Quantified blood loss was 350 mL at birth plus 150 mL in the next 10 minutes, and bleeding continues. The fundus is soft, 2 cm above the umbilicus, and deviated to the right; the bladder is palpable above the symphysis, and the client last voided before pushing. The placenta appeared complete, and no laceration is visible. The client reports dizziness and no rectal pressure. HR 112/min, BP 94/58 mm Hg (148/92 during labor), capillary refill 3 seconds, SpO2 98% with a faint end-expiratory wheeze noted at prenatal visits. Complete the diagram by selecting the condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Condition

Select 1
Genital tract laceration
Retained placental tissue
Vaginal wall hematoma
Uterine atony

Actions to take

Select 2
Massage the fundus until it becomes firm
Apply an ice pack to the perineum
Place the client in the Trendelenburg position
Activate the obstetric hemorrhage protocol
Assist the client to the bathroom to void

Parameters to monitor

Select 2
Quantified blood loss
Oral temperature
Deep tendon reflex response
Fundal tone and position
Perineal pain rating

## Explanation

A soft, high fundus with continuing bleeding after prolonged oxytocin-augmented labor, a complete placenta, and no visible laceration points to uterine atony; 500 mL with HR 112 and BP 94/58 is hemorrhage with early hypovolemia. Fundal massage and activating the hemorrhage protocol address it now. Quantified blood loss and fundal tone show whether bleeding is controlled.

## In-depth explanation

Quick answer
Uterine atony with postpartum hemorrhage. Take action: fundal massage and activate the obstetric hemorrhage protocol. Monitor: quantified blood loss and fundal tone and position.

Why this is correct
Prolonged labor with oxytocin augmentation exhausts the myometrium. A boggy fundus that bleeds while the placenta is complete and no tear is seen makes loss of tone the primary source; the full bladder is displacing the uterus to the right and adds to atony. A shock index of 112/94 ≈ 1.2 with dizziness means this is already a hemorrhage, not heavy lochia, so a team response with uterotonics, access, and blood readiness is needed in parallel with massage. Measured loss and uterine firmness are the direct readouts of whether the uterus is clamping down.

Easy analogy or mental picture
Think of the uterus as a sponge of blood vessels held shut by muscle. When the muscle relaxes, the sponge drips; massage squeezes it, the protocol brings the medicines that keep it squeezed, and a scale tells you if the dripping stopped.

Memory hook
Boggy + bleeding = RUB and RALLY (massage, protocol); WEIGH and FEEL (QBL, fundus).

NCLEX decision rule
Match the bleeding source to the exam: soft fundus = tone; firm fundus with bleeding = trauma; firm fundus with pain and pressure = hematoma. Treat the source you can act on now and escalate when the shock index exceeds 1.

Why the other choices are wrong
A laceration bleeds with a firm, contracted uterus, and none is visible; retained tissue is less likely with a complete placenta; a hematoma causes severe pain or rectal pressure with little visible bleeding. Trendelenburg is outdated and impairs ventilation without restoring volume. Emptying the bladder helps, but walking a dizzy, hypotensive client to the bathroom risks a fall — the bladder should be drained by catheter as part of the protocol. Ice to the perineum is for edema or small hematomas. Temperature tracks endometritis, reflexes track magnesium or preeclampsia, and perineal pain tracks hematoma rather than atony.

References
1ACOG Practice Bulletin 183: Postpartum HemorrhageAtony as leading cause, uterine massage, hemorrhage bundle activation, and quantified blood loss
2WHO Consolidated Guidelines for Postpartum HaemorrhageEarly detection by measured blood loss and first-response treatment bundle for postpartum haemorrhage

## Clinical scenario

Case update
Bleeding continues. The client reports dizziness, the uterus remains boggy, and the hemorrhage protocol is available.

## Key concepts

- **Uterine atony** — Failure of the myometrium to contract after birth, the most common cause of postpartum hemorrhage.
- **Quantified blood loss** — Blood loss measured by weighing and collecting rather than visual estimation.
- **Shock index** — Heart rate divided by systolic blood pressure; a value above 1.0 after birth signals significant blood loss.

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