After completing post anesthesia recovery assessments, the registered nurse (RN) asks the practical nurse (PN) to transfer four clients, each two hours post-birth, to the postpartum unit. Which client should the PN ask the RN to reassess prior to transfer?

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.

Choice A rationale:

Prescribing medication for immediate relief is not the primary goal when establishing a therapeutic relationship with a client with anxiety disorder. While medication may be a part of the treatment plan, the primary focus should be on building trust and addressing the client's emotional needs.

Choice B rationale:

Educating the client about various relaxation techniques can be beneficial, but it is not the primary goal of establishing a therapeutic relationship. The primary goal is to create a trusting and supportive environment in which the client feels comfortable discussing their feelings and concerns.

Choice C rationale:

Assisting the client in challenging irrational thoughts is an important aspect of cognitive-behavioral therapy, but it is not the primary goal of establishing the therapeutic relationship. Building rapport and trust come first.

Choice D rationale:

Developing measurable and realistic outcomes is the primary goal when establishing a therapeutic relationship. These outcomes provide a framework for assessing progress and ensuring that the therapeutic interventions are effective in addressing the client's anxiety disorder.