# Twelve minutes after a vaginal birth, a client continues to bleed. Prophylactic oxytocin was given after the birth, and the placenta was inspected and found intact. Quantified blood loss is 700 mL and rising. The client is pale with heart rate 124/min and blood pressure 88/50 mm Hg. The uterus is boggy, 2 cm above the umbilicus, and displaced to the right; it firms temporarily and the flow slows during massage, then relaxes again. The client has not voided since before the birth. The perineum has a small first-degree laceration that is not actively bleeding. 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) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=617362&lang=en > language: en > subject: Hemodynamics > category: PA ## Question Twelve minutes after a vaginal birth, a client continues to bleed. Prophylactic oxytocin was given after the birth, and the placenta was inspected and found intact. Quantified blood loss is 700 mL and rising. The client is pale with heart rate 124/min and blood pressure 88/50 mm Hg. The uterus is boggy, 2 cm above the umbilicus, and displaced to the right; it firms temporarily and the flow slows during massage, then relaxes again. The client has not voided since before the birth. The perineum has a small first-degree laceration that is not actively bleeding. 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 Cervical or vaginal laceration Retained placental fragments Uterine atony Uterine inversion Actions to take Select 2 Prepare for repair of a genital-tract laceration Massage the uterine fundus firmly Prepare for manual removal of placental tissue Place the client in Trendelenburg position Empty the bladder by straight catheterization Parameters to monitor Select 2 Fundal tone and position Perineal pain intensity score Oral temperature Quantified blood loss total Lochia odor ## Explanation A boggy, enlarged uterus that firms and reduces bleeding with massage points to uterine atony; displacement to the right and no voiding since birth show a distended bladder preventing contraction. The nurse massages the fundus and empties the bladder while the hemorrhage response continues. Fundal tone and position plus cumulative quantified blood loss show whether bleeding is controlled. ## In-depth explanation Quick answer Uterine atony; massage the fundus and empty the bladder by straight catheterization; monitor fundal tone and position and cumulative quantified blood loss. Why this is correct Bleeding that slows when the uterus firms under massage comes from the placental site, which means tone is the problem. The fundus is above the umbilicus and pushed to the right, and the client has not voided, so a full bladder is keeping the uterus from contracting. Massage and bladder emptying restore contraction; fundal firmness, return to midline, and the quantified blood-loss total show success. Easy analogy or mental picture The uterus is a sponge that has to be squeezed shut over open vessels. A full bladder is a book wedged under the sponge, so it cannot close no matter how hard you press. Memory hook Boggy + shifted = rub and drain (massage the fundus, empty the bladder). NCLEX decision rule When postpartum bleeding responds to fundal massage and the uterus is displaced, treat tone first and empty the bladder; look for trauma or tissue only when the uterus is firm and bleeding continues. Why the other choices are wrong A laceration bleeds despite a firm uterus; here bleeding slows with massage and the small first-degree tear is not bleeding, so repair and perineal pain do not track the hemorrhage. Retained tissue is unlikely with an intact placenta, so manual removal is not indicated, and lochia odor tracks later infection. Uterine inversion causes a missing or dimpled fundus, not a high displaced one. Trendelenburg positioning is an outdated shock measure that impairs ventilation and does not treat the cause. Temperature reflects infection, not bleeding control. References 1WHO — Recommendations on the assessment and management of postpartum haemorrhageUterine massage, uterotonics, and bundled first-response care for PPH 2NCSBN 2026 NCLEX-RN Test PlanClient Needs category and clinical judgment framework ## Clinical scenario Scenario Early postpartum hemorrhage with a boggy, displaced uterus that firms only temporarily with massage in a client who has not voided since birth. ## Key concepts - **Uterine atony** — Loss of uterine muscle tone that allows the placental site to keep bleeding. - **Quantified blood loss** — Measured blood loss by weighing and collecting, more accurate than visual estimation. - **Fundal displacement** — A fundus shifted from midline, usually by a distended bladder. ## Related questions - [A client with septic shock is being reassessed after initial treatment. For each finding, …](https://mymerci.kr/pages/nclex_q.php?qn_id=393412&lang=en) - [A client with chronic obstructive pulmonary disease is sitting upright, using accessory mu…](https://mymerci.kr/pages/nclex_q.php?qn_id=396589&lang=en) - [A client with septic shock has received the prescribed crystalloid bolus. The mean arteria…](https://mymerci.kr/pages/nclex_q.php?qn_id=397262&lang=en) - [A client arrives with sudden right-sided weakness and aphasia. The family states the clien…](https://mymerci.kr/pages/nclex_q.php?qn_id=397320&lang=en) - [A client who takes apixaban was admitted after a fall. The abdomen is now firm and tender,…](https://mymerci.kr/pages/nclex_q.php?qn_id=522676&lang=en) ## Read in another language - [en](https://mymerci.kr/pages/nclex_q.php?qn_id=617362&lang=en) - [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=617362&lang=ko) - [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=617362&lang=ja) - [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=617362&lang=zh-tw) - [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=617362&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._