In assessing a 2-year-old boy with croup, the practical nurse (PN) finds that he has become increasingly irritable and has developed tachypnea and resting stridor. Which intervention is best for the PN to implement?

The correct answer is choice B. Attach the drainage bag to the bed frame.

Choice A rationale:

Measuring the urinary output in the bag is a routine task but does not address the improper placement of the drainage bag. The immediate concern is to ensure the drainage bag is correctly positioned to prevent complications.

Choice B rationale:

Attaching the drainage bag to the bed frame is the correct action. The drainage bag should be kept below the level of the bladder and attached to a non-movable part of the bed to prevent backflow and reduce the risk of infection.

Choice C rationale:

Applying gloves and emptying the drainage bag is not the immediate priority. The drainage bag should not be allowed to overfill, but in this scenario, it is only half-full, so this action is not urgent.

Choice D rationale:

Removing the looped tubing from the bed is important to ensure proper drainage and prevent backflow, but it does not address the incorrect placement of the drainage bag, which is the primary concern in this situation.

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.