The practical nurse (PN) observes unlicensed assistive personnel (UAP) bathing a bedfast client with the bed in a high position. 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.

The PN should directly observe the UAP's performance and provide feedback and guidance as needed. This can help ensure that the UAP follows the standards of care and respects the client's dignity and preferences.

The other options are not correct because:

A. Asking another UAP to help the oriented may not be appropriate or necessary, as it may interfere with the orientation process and create confusion or conflict.

B. Verifying with the client that the bath was complete and thorough may not be sufficient or reliable, as the client may not be able to assess the quality of care or may not want to complain.

C. Inspecting the client's skin near the end of the bathing procedure may not be timely or comprehensive, as it may miss some aspects of care or some problems that occurred during the bath.