# Clinical context: Two hours after a vaginal birth, a client saturates a perineal pad in 12 minutes with continuous bright-red bleeding. The uterus is boggy and above the umbilicus. BP is 84/50 mm Hg and HR 126/min; the skin is pale and cool, and the client reports dizziness. The client had severe-range blood pressure earlier in labor and has active asthma that required rescue albuterol this week. The placenta was documented as intact, the bladder is nondistended, and no perineal swelling is seen. 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=617382&lang=en  
> language: en  
> subject: Adverse Effects/Contraindications/Interactions  
> category: PPT

## Question

Clinical context: Two hours after a vaginal birth, a client saturates a perineal pad in 12 minutes with continuous bright-red bleeding. The uterus is boggy and above the umbilicus. BP is 84/50 mm Hg and HR 126/min; the skin is pale and cool, and the client reports dizziness. The client had severe-range blood pressure earlier in labor and has active asthma that required rescue albuterol this week. The placenta was documented as intact, the bladder is nondistended, and no perineal swelling is seen.

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
Hemorrhage from a genital-tract laceration
Hemorrhage from retained placental tissue
Hemorrhage from uterine atony
Uterine displacement from a full bladder

Actions to take

Select 2
Give prescribed methylergonovine 0.2 mg IM
Massage the uterine fundus firmly
Give prescribed carboprost 250 mcg IM
Insert a straight catheter to empty the bladder
Increase the prescribed oxytocin infusion

Parameters to monitor

Select 2
Uterine fundal tone
Peak expiratory flow rate
Deep tendon reflexes
Quantitative blood loss
Perineal hematoma size

## Explanation

A boggy uterus with brisk bright-red bleeding, an intact placenta, and an empty bladder points to uterine atony as the cause of this hemorrhage. Fundal massage and the prescribed oxytocin infusion are the safe first-line measures; methylergonovine is contraindicated by the severe-range blood pressure and carboprost by the active asthma. Fundal tone and quantitative blood loss show whether the uterus is contracting and the bleeding is slowing.

## In-depth explanation

Quick answer
Hemorrhage from uterine atony. Massage the fundus and increase the prescribed oxytocin infusion. Monitor fundal tone and quantitative blood loss.

Why this is correct
Uterine atony causes most postpartum hemorrhage: the relaxed myometrium cannot compress the placental-site vessels, so bleeding is brisk and the uterus feels soft and high. The documented intact placenta, empty bladder, and absent perineal swelling remove the other common causes. Oxytocin is the first-line uterotonic and is safe with hypertension and asthma, whereas methylergonovine can cause a hypertensive crisis and carboprost can trigger bronchospasm.

Easy analogy or mental picture
The uterus after birth is like a mesh of muscle fibers wrapped around open vessels. When the mesh tightens, the vessels are squeezed shut; when it goes slack, they pour. Massage and oxytocin tighten the mesh.

Memory hook
"Boggy = massage + oxytocin." Methergine skips high BP; Hemabate skips asthma.

NCLEX decision rule
For postpartum bleeding, find the cause with the 4 Ts (tone, trauma, tissue, thrombin), treat tone first when the uterus is boggy, and check each uterotonic against the client's contraindications before giving it.

Why the other choices are wrong
A laceration bleeds with a firm uterus, and retained tissue requires an incomplete placenta; here the uterus is boggy and the placenta intact, so hematoma checks do not track the problem. A full bladder can push the uterus up, but this bladder is nondistended, so catheterization would not treat the cause. Methylergonovine and carboprost are real second-line uterotonics, which makes them tempting, but severe-range blood pressure and active asthma contraindicate them; peak flow would only matter if carboprost had been given. Deep tendon reflexes track magnesium therapy for preeclampsia, not hemorrhage.

References
1ACOG Practice Bulletin No. 183: Postpartum HemorrhageUterine atony is the most common cause; first-line uterotonic is oxytocin; methylergonovine is contraindicated in hypertension and carboprost in asthma
2CMQCC: OB Hemorrhage ToolkitStaged hemorrhage response with fundal massage, bladder emptying, uterotonics, and quantitative blood loss measurement
3WHO recommendation on tranexamic acid for the treatment of postpartum haemorrhageEarly tranexamic acid within 3 hours of birth is recommended in addition to standard care for postpartum hemorrhage

## Clinical scenario

Case update
Uterine-atony postpartum hemorrhage with hypovolemia in a client with active asthma and severe-range blood pressure in labor.

## Key concepts

- **Uterine atony** — Failure of the uterus to contract after birth, the most common cause of postpartum hemorrhage.
- **Quantitative blood loss (QBL)** — Measured blood loss using graduated collection and weighed pads rather than visual estimation.
- **Uterotonic contraindication** — A condition that makes a specific uterine-contracting drug unsafe, such as hypertension for methylergonovine or asthma for carboprost.

## Related questions

- [A client is admitted to the emergency department after ingesting an unknown amount of acet…](https://mymerci.kr/pages/nclex_q.php?qn_id=362720&lang=en)
- [A client with chronic heart failure is prescribed metoprolol 25 mg orally twice daily. Bef…](https://mymerci.kr/pages/nclex_q.php?qn_id=362756&lang=en)
- [A 28-year-old client with type 1 diabetes receives regular insulin 6 units and NPH insulin…](https://mymerci.kr/pages/nclex_q.php?qn_id=362792&lang=en)
- [A client receives IV vancomycin 1 g every 12 hours for MRSA bacteremia. Before the next do…](https://mymerci.kr/pages/nclex_q.php?qn_id=362833&lang=en)
- [A client with bipolar disorder has been taking lithium carbonate 600 mg orally three times…](https://mymerci.kr/pages/nclex_q.php?qn_id=362894&lang=en)
- [A nurse is monitoring a client receiving a continuous IV heparin infusion for pulmonary em…](https://mymerci.kr/pages/nclex_q.php?qn_id=363988&lang=en)
- [A nurse is preparing to initiate a weight-based continuous IV unfractionated heparin infus…](https://mymerci.kr/pages/nclex_q.php?qn_id=364107&lang=en)
- [A nurse is providing discharge teaching to a 65-year-old client newly prescribed warfarin …](https://mymerci.kr/pages/nclex_q.php?qn_id=364872&lang=en)

## Read in another language

- [en](https://mymerci.kr/pages/nclex_q.php?qn_id=617382&lang=en)
- [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=617382&lang=ko)
- [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=617382&lang=ja)
- [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=617382&lang=zh-tw)
- [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=617382&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._