# Stage 3 — Prioritize hypotheses. A 28-year-old G3P3 client gave birth vaginally 60 minutes ago to a 4.1-kg infant after a 14-hour oxytocin-augmented labor; she had a postpartum hemorrhage after her last birth. The placenta delivered intact. Since birth she has voided a small unmeasured amount only once. BP is 92/58 (admission 124/78), HR 116, RR 22, temperature 36.9°C (98.4°F), and SpO2 98%. She is pale and lightheaded. The uterus is soft and boggy, with the fundus 2 cm above the umbilicus and deviated to the right. Lochia is heavy with clots, and cumulative quantitative blood loss is 700 mL. The perineum is intact with mild edema, and blood is clotting on the pads. 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=617387&lang=en  
> language: en  
> subject: Ante/Intra/Postpartum and Newborn Care  
> category: HPM

## Question

Stage 3 — Prioritize hypotheses. A 28-year-old G3P3 client gave birth vaginally 60 minutes ago to a 4.1-kg infant after a 14-hour oxytocin-augmented labor; she had a postpartum hemorrhage after her last birth. The placenta delivered intact. Since birth she has voided a small unmeasured amount only once. BP is 92/58 (admission 124/78), HR 116, RR 22, temperature 36.9°C (98.4°F), and SpO2 98%. She is pale and lightheaded. The uterus is soft and boggy, with the fundus 2 cm above the umbilicus and deviated to the right. Lochia is heavy with clots, and cumulative quantitative blood loss is 700 mL. The perineum is intact with mild edema, and blood is clotting on the pads. 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 fragments
Hemorrhage from a coagulation disorder
Hemorrhage from uterine atony

Actions to take

Select 2
Prepare for manual removal of placental tissue
Massage the uterine fundus until firm
Prepare for repair of a vaginal laceration
Catheterize to empty the bladder
Prepare to transfuse fresh frozen plasma

Parameters to monitor

Select 2
Quantitative blood loss
REEDA score of the perineum
Serum D-dimer level
Oral temperature
Fundal tone and position

## Explanation

A soft, boggy uterus that is high and deviated to the right, heavy clotted lochia with QBL 700 mL, and falling blood pressure indicate postpartum hemorrhage from uterine atony, worsened by a full bladder. The nurse massages the fundus and empties the bladder so the uterus can contract, while the hemorrhage response continues. Quantitative blood loss and fundal tone and position show whether bleeding is being controlled.

## In-depth explanation

Quick answer
Hemorrhage from uterine atony. Massage the fundus until firm and catheterize to empty the bladder. Monitor quantitative blood loss and fundal tone and position.

Why this is correct
A boggy uterus is the defining sign of atony, and prolonged oxytocin-augmented labor, a large infant, and a previous PPH are all risk factors. A fundus that is high and pushed to one side suggests a distended bladder, which keeps the uterus from contracting; emptying it is part of treating the atony. The intact placenta, intact perineum, and clotting blood make the other causes of bleeding less likely.

Easy analogy or mental picture
A full bladder is like a pillow wedged under a balloon you are trying to squeeze: you cannot compress it fully until the pillow is removed. Massage squeezes; emptying the bladder removes the pillow.

Memory hook
"High and to the right? Empty the bladder, then rub." Boggy means tone.

NCLEX decision rule
For postpartum bleeding with a boggy uterus, treat tone first with massage and bladder emptying while the team escalates uterotonics; monitor measured blood loss and fundal findings to judge response.

Why the other choices are wrong
A laceration bleeds despite a firm uterus, and the perineum is intact, so preparing for repair and REEDA scoring do not address this bleeding. Retained fragments require an incomplete placenta, but it delivered intact, so manual removal is not the first step. A coagulation disorder is unlikely when blood is clotting normally, so plasma and D-dimer (which is normally raised after birth) are not the right targets. Temperature tracks infection such as endometritis, which is not the current problem.

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

## Clinical scenario

Case update
One hour after birth, the uterus is boggy and displaced to the right with QBL 700 mL and early hypovolemic signs.

## Key concepts

- **4 Ts of postpartum hemorrhage** — Tone, trauma, tissue, and thrombin: the four main causes checked when bleeding is excessive.
- **Fundal deviation** — A fundus displaced to one side, usually the right, often caused by a distended bladder.
- **Fundal massage** — Firm rubbing of the uterine fundus to stimulate contraction while the lower segment is supported.

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