A nurse is collecting data from an adolescent who is postoperative and is receiving morphine for pain. Which of the following findings is the nurse's priority?

Choice A reason:

Hep B is given at birth, 2 months, and 6 months of age not at 11 years old.

Choice B reason:

Measles, mumps, rubella (MMR) The rationale for not choosing Measles, mumps, rubella (MMR) is the same as for choice A. If the child has already received the required doses of the MMR vaccine, giving extra doses is not necessary and may not provide any additional benefit.

Choice C reason:

This vaccine is recommended for children at age 11-12 years to boost immunity against tetanus, diphtheria, and pertussis. This is a one-time dose, and it's important to ensure that children receive it on schedule.

Choice D reason:

Pneumococcal (PCV) The rationale for not choosing Pneumococcal (PCV) is that this vaccine is typically given in infancy and early childhood as part of the routine immunization schedule.

Since the child is 11 years old and up to date with current recommendations, they are unlikely to require another dose of PCV at this stage.

Choice A reason:

The client stating, "I should add 500 calories per day to my diet,” is not an accurate understanding of breastfeeding. While it is true that breastfeeding mothers require additional calories to support lactation, the specific amount of calories needed varies depending on individual factors and should be discussed with a healthcare professional. Simply adding 500 calories per day may not be appropriate for every woman and could lead to excessive weight gain.

Choice B reason:

This choice indicates an understanding of proper breast hygiene during breastfeeding. Using antibacterial soap and warm water to wash the breasts helps to prevent infection and maintain good breast health, reducing the risk of complications for both the mother and the baby.

Choice C reason:

The statement, "Breastfeeding is a reliable method of birth control,” is incorrect. While breastfeeding can provide some natural contraceptive effects, it is not a foolproof method of birth control. This concept is known as the lactational amenorrhea method (LAM), and specific criteria must be met for it to be considered a reliable form of contraception. Relying solely on breastfeeding as birth control can lead to an unintended pregnancy.

Choice D reason:

The statement, "If my nipples become cracked and red, I will apply hydrocortisone cream,” is not advisable. While hydrocortisone cream may provide temporary relief from irritation, it is not recommended for breastfeeding mothers. Ingestion of the cream by the baby can be harmful. Instead, the client should seek guidance from a healthcare professional to address and resolve any breastfeeding-related nipple issues.