The practical nurse (PN) observes an unlicensed assistive personnel (UAP) performing oral hygiene on an unconscious client who is lying in a flat side-lying position with an emesis basin on a towel under the chin. Which action should the PN take?

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.

Choice A rationale:
Asking another nurse about administering adult dosages to children may provide some insights, but it is not a reliable or definitive source of information. The PN should directly communicate with the healthcare provider who wrote the prescription to ensure accuracy and safety.
Choice B rationale:
Call the healthcare provider and clarify the prescription.
Choice C rationale:
While requesting verification from the charge nurse is reasonable, the charge nurse may not have the authority to change or clarify the prescription. The most appropriate action is to directly contact the healthcare provider responsible for the child's care.
Choice D rationale:
Telling the pharmacy to send an accurate child's dosage assumes that the pharmacy made an error, which may not be the case. The PN should confirm the prescription with the healthcare provider to avoid potential mistakes or misunderstandings.