A 15-year-old adolescent male with a mild mental disability is hospitalized for minor surgery and tells the practical nurse (PN), "Wow! You have big breasts."

Which response is best for the PN to provide?

This is the finding that the PN should instruct the postpartum client to report to the charge nurse because it may indicate an infection, such as endometritis, mastitis, or urinary tract infection, that requires prompt treatment. The PN should also instruct the client to monitor for other signs of infection, such as foul-smelling lochia, redness or tenderness of the breasts, or dysuria.

A. Increased diaphoresis during the day and night is a normal finding in the postpartum period and does not need to be reported. It is caused by hormonal changes and fluid shifts that occur after delivery.

B. Breast engorgement on the fourth postpartum day is a normal finding in the postpartum period and does not need to be reported. It is caused by increased blood flow and milk production in the breasts.

C. Lochia color that changes to light pink or white is a normal finding in the postpartum period and does not need to be reported. It indicates that the uterine lining is healing and regenerating after delivery.

Choice A rationale:

Offering a high protein diet may not be appropriate for a client with hepatic failure. High protein intake can lead to the accumulation of ammonia in the bloodstream, worsening hepatic encephalopathy. Therefore, this choice is not the best intervention for the client.

Choice B rationale:

Performing range of motion exercises is important for clients with hepatic failure to prevent complications related to immobility. However, it does not directly address the client's elevated pulse rate and changes in mental status.

Choice C rationale:

Weighing the client every morning is essential in monitoring fluid status and identifying signs of fluid retention or dehydration, which are common in hepatic failure. Changes in weight can help detect early signs of worsening hepatic function.

Choice D rationale:

Providing only distilled water may not be appropriate for a client with hepatic failure. While it is essential to monitor fluid intake, restricting all fluids to only distilled water could lead to electrolyte imbalances and further complications. Monitoring overall fluid intake and type is important for these clients.