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:

Take this medication every day for regular bowel movements. Rationale: This choice is incorrect. Docusate sodium is a stool softener used to prevent constipation, but it should not be taken daily for regular bowel movements. Overuse of stool softeners can lead to dependence and may disrupt the natural bowel function.

Choice B reason:

Take the medication with mineral oil. Rationale: This choice is incorrect. Docusate sodium should not be taken with mineral oil. When taken together, they can form a mixture that is difficult for the body to absorb, leading to potential adverse effects.

Choice C reason:

Decrease dietary fiber intake while taking this medication. Rationale: This choice is incorrect. It is not advisable to decrease dietary fiber intake while taking docusate sodium. Fiber is essential for promoting regular bowel movements and overall gastrointestinal health.

Combining the medication with a high-fiber diet can enhance its effectiveness.

Choice D reason:
Take the medication with a full glass of water. Rationale: This choice is correct. The nurse should instruct the client to take docusate sodium with a full glass of water. The water helps to soften the stool and allows the medication to work effectively in preventing constipation.

Choice B reason: The nurse should ask the client if they have had thoughts about harming their infant. This is a crucial action because the client's statement suggests they may be experiencing feelings of inadequacy and self-doubt as a mother, which could potentially lead to more serious thoughts or actions. By directly asking about thoughts of harming the baby, the nurse can assess the client's mental and emotional state more thoroughly and determine if there is a risk of harm to the infant.

Choice A reason:

The nurse should advise the client that most new mothers experience these feelings. This response acknowledges the client's feelings of inadequacy and normalizes their experience, letting them know that it is common for new mothers to have doubts and insecurities. This validation can help the client feel less alone and more understood, promoting a therapeutic nurse-client relationship.

Choice C reason:

The nurse should explain to the client that they are experiencing the "baby blues.” This is a valid option because the client's statement indicates they may be experiencing mood swings, sadness, and emotional sensitivity, which are typical symptoms of the baby blues. Providing this information can help the client understand that these feelings are transient and often related to hormonal changes after childbirth.

Choice D reason:

Taking the client to the emergency department is not warranted based solely on the information provided. The client's statement does not indicate an immediate danger to themselves or their baby. However, if during the assessment (including choice B), the nurse identifies any signs of potential harm to the infant or the client, further action may be necessary, such as involving appropriate mental health professionals or support services.