A nurse is assisting in the care of an adolescent.

The nurse is reviewing the data collection findings.

Select the 5 findings the nurse should report to the provider.

• Lung assessment: The client's lungs are clear bilaterally with no signs of respiratory distress or abnormal breath sounds. There is no indication of pulmonary complications, so no further immediate action is needed regarding the lung assessment.
• Vertigo: Vertigo is a common complication following a stapedectomy due to disturbance of the inner ear structures. However, it still requires monitoring because severe or worsening vertigo can increase the risk of falls and indicate inner ear trauma or dysfunction.
• Facial nerve assessment: The presence of left facial droop and asymmetrical smile indicates possible injury to the facial nerve during surgery. This finding is abnormal and requires immediate provider notification for further neurological evaluation and management.
• Pain rating: A pain rating of 5 out of 10 is moderate and, following ear surgery, it should be addressed. Proper pain control is important not only for comfort but also to reduce the risk of increased intracranial pressure from straining or agitation.
• Diminished hearing: Some decrease in hearing can occur temporarily after a stapedectomy due to packing or swelling, but it still needs further monitoring. Persistent or worsening hearing loss could suggest a surgical complication, such as prosthesis dislocation.
• Pupils: The pupils are equal, smaller postoperatively but still reactive to light, which is expected following anesthesia and is not concerning. No immediate intervention is necessary based on pupil assessment findings.

A. Promote bonding by encouraging the guardians to formula feed their newborn: Bonding occurs through close physical contact, responsiveness, and nurturing care, regardless of the feeding method. Bonding is important regardless of feeding method, but feeding choice should be based on the guardians’ preference, not directed solely by the nurse. Formula feeding is not necessary for promoting bonding.

B. Encourage guardians to allow relatives to provide the majority of the care for their newborn: Guardians should be encouraged to provide the majority of the newborn's care themselves to strengthen attachment and build confidence in their parenting abilities.

C. Ensure guardians know that criticism of newborn care is acceptable: Criticism can undermine the guardians' confidence and create stress. Support and positive reinforcement are important for helping new parents feel secure in their roles.

D. Inform guardians how to respond to their newborn's cues: Teaching guardians how to recognize and respond to their newborn's cues, such as hunger, discomfort, or need for interaction, promotes bonding, supports emotional development, and strengthens the parent-newborn relationship.