A newly hired unlicensed assistive personnel (UAP) is assigned to a home healthcare team along with two experienced UAPs.
Which intervention should the home health nurse implement to ensure adequate care for all clients?

Choice A rationale:

Providing information about the client's healthcare power of attorney is not the most critical piece of information to report in this situation. The immediate concern is the client's change in mental status and potential medical emergency.

Choice B rationale:

While the reason for the client's admission is important background information, it is not the most urgent information to report in this situation. The priority is addressing the client's acute change in mental status.

Choice C rationale:

The nurse should be aware of the client's currently prescribed medications, but this information does not take precedence over the client's sudden onset of confusion and agitation. Immediate action is needed to address the client's altered mental status.

Choice D rationale:

Increasing confusion and agitation in a client who recently underwent ORIF of the right femur is a significant change in condition and may indicate a medical emergency such as infection, delirium, or other complications. This information should be provided first to alert the healthcare provider to the client's immediate needs.

The correct answer and explanation is:

d) Massage the fundus and avoid direct pressure on the cesarean incision.

This is the best action to take for a client who experiences a sudden gush of vaginal blood and clots after a

cesarean section. Massaging the fundus helps to stimulate uterine contractions and reduce bleeding.

Avoiding direct pressure on the incision prevents pain and wound dehiscence.

a) Insert an indwelling catheter to empty the bladder and contract the fundus.

This is not the first action to take for a client who experiences a sudden gush of vaginal blood and clots after a cesarean section. Inserting an indwelling catheter requires a physician's order and may cause discomfort and infection. The client may already have a catheter in place after the surgery.

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

This is not enough to do for a client who experiences a sudden gush of vaginal blood and clots after a cesarean section. Checking fundal consistency and monitoring lochial flow are important, but they do not address the cause of bleeding or prevent further blood loss.

c) Return the client to bed and maintain bedrest until the lochial flow slows.

This is not appropriate for a client who experiences a sudden gush of vaginal blood and clots after a cesarean section. Returning the client to bed and maintaining bedrest may delay ambulation and increase the risk of thromboembolism. It also does not stop the bleeding or treat the underlying cause.