A male college student brings his roommate to the clinic because the roommate has been talking to someone who is not present. The client tells the practical nurse (PN) that the voices are saying, "Kill, kill.”. Which question should the PN ask the client next?

Check fundal consistency and continue to monitor the lochial flow amount.

Choice A rationale:

Inserting an indwelling catheter to empty the bladder and contract the fundus is not the appropriate action for a sudden gush of vaginal blood and blood clots. The priority here is to assess the fundus, not intervene with an indwelling catheter. Catheterization may be necessary for other reasons, but not in this context.

Choice B rationale:

Returning the client to bed and maintaining bedrest until the lochial flow slows may be a reasonable initial response, but it is not the most appropriate action. The sudden gush of blood and presence of blood clots could be indicative of postpartum hemorrhage or retained placental tissue, which require prompt evaluation.

Choice C rationale:

Checking fundal consistency and continuing to monitor the lochial flow amount is the most appropriate action. The sudden gush of blood and clots suggest a possible uterine atony or retained products of conception. Assessing the fundal height and firmness helps identify if the uterus is contracting adequately, while monitoring the lochial flow amount can indicate ongoing bleeding.

Choice D rationale:

Massaging the fundus and avoiding direct pressure on the cesarean incision is not the recommended action in this situation. Massaging the fundus without assessing its consistency could worsen bleeding if there is uterine atony, and the client needs immediate evaluation and monitoring.

The correct answer is choice D. Apply a pain scale to describe intensity.

Choice A rationale:

Asking about elements of the pain experience is important for a comprehensive pain assessment, but it is not the most critical aspect immediately after administering an analgesic. This step is more relevant during the initial assessment to understand the nature and characteristics of the pain.

Choice B rationale:

Questioning the client about precipitating factors can help identify what triggers the pain, which is useful for long-term pain management strategies. However, this is not the primary focus after giving an analgesic, as the immediate goal is to evaluate the effectiveness of the pain relief.

Choice C rationale:

Locating where in the body the pain occurs is essential for diagnosing and understanding the pain’s origin. However, after administering an analgesic, the priority is to assess the change in pain intensity rather than its location.

Choice D rationale:

Applying a pain scale to describe intensity is crucial after giving an analgesic because it provides a quantifiable measure of the pain relief achieved. This helps in determining the effectiveness of the medication and guides further pain management interventions.

By focusing on the pain intensity using a standardized pain scale, the practical nurse can objectively evaluate the patient’s response to the analgesic and make informed decisions about any additional pain management needs.