PEDS Exam #3

After assessing a client with chronic obstructive pulmonary disease (COPD) who is being tested with beclomethasone dipropionate (Beclovent) via oral steroid inhaler, which clinical manifestations would the nurse conclude are side effects of this medication? Select all that apply:

1. Delayed healing 2. Oral fungal infection 3. Weight Gain

The nurse is caring for a 10-month-old infant with respiratory syncytial virus (RSV) bronchiolitis. Which of the following interventions should be included in the child's care? (Select all that apply.)

Encourage to drink 8 ounces of formula every 4 hours. Cluster care to encourage adequate rest. Place on noninvasive oxygen monitoring. Rationale: Hydration is important in children with RSV bronchiolitis to loosen secretions and prevent shock. Clustering of care promotes periods of rest. The use of noninvasive oxygen monitoring is recommended

A nurse reviews the record of a 3-week-old infant and notes that the health care provider has documented a diagnosis of suspected Hirschsprung's disease. The nurse understands that which of the following symptoms led the mother to seek health care for the infant?

Foul-smelling, ribbon-like stools Rationale: Chronic constipation that begins during the first month of life and that results in foul-smelling, ribbon-like or pellet-like stools is a clinical manifestation of Hirschsprung's disease. The delayed passage or absence of meconium stool during the neonatal period is a characteristic sign. Bowel obstruction (especially during the neonatal period), abdominal pain and distention, and failure to thrive are also clinical manifestations. Options 1, 2, and 3 are incorrect.

A child has been diagnosed with meningococcal meningitis. Which precautionary technique is appropriate to prevent transmission of the disease?

Isolation precautions for at least 24 hours after the initiation of antibiotics. Rationale: Meningococcal meningitis is transmitted primarily by droplet infection. Isolation is begun & maintained for at least 24 hours after antibiotics are given.

A nurse is caring for a newborn with spina bifida (myelomeningocele type) who is scheduled for the removal of the gibbus (sac on the back filled with cerebrospinal fluid, meninges, and some of the spinal cord). In the preoperative period, the priority nursing action is to monitor:

Moisture of the normal saline dressing on the gibbous area Rationale: The newborn is at risk for infection before closure of the gibbus. A sterile normal saline dressing is placed over the gibbus to maintain moisture of the gibbus and its contents. This prevents tearing or breakdown of the skin integrity at the site. Blood pressure is difficult to determine during the newborn period and is not the best indicator of infection. Urine concentration is not well developed in the newborn stage of development. Depression of the anterior fontanel is a sign of dehydration. With spina bifida, an increase in intracranial pressure is more of a priority. A complication of spina bifida would demonstrate a bulging or taut anterior fontanel.

An infant returns to the nursing unit after the surgical repair of a cleft lip located on the right side of the lip. The best position in which to place this infant at this time is:

On his or her left side Rationale: After the repair of a cleft lip, the infant should be positioned on the side opposite to the repair to prevent contact of the suture lines with the bed linens. In this case, it is best to place the infant on his or her left side. Additionally, the flat or prone position can result in aspiration if the infant vomits.

A nurse reinforces home-care instructions to the parents of a child with celiac disease. Which of the following food items would the nurse advise the parents to include in the child's diet?

Rice Rationale: Dietary management is the mainstay of treatment for celiac disease. All wheat, rye, barley, and oats should be eliminated from the diet and replaced with corn and rice. Vitamin supplements, especially fat-soluble vitamins and folate, may be required during the early period of treatment to correct deficiencies. These restrictions are likely to be lifelong, although small amounts of grains may be tolerated after the gastrointestinal ulcerations have healed.

After a tonsillectomy, the child begins to vomit bright red blood. Which is the initial nursing action?

Turn the child on the side. Rationale: After a tonsillectomy, if bleeding occurs, the child is turned to the side, & the R.N. or H.C.P. is notified. An N.P.O. status would be maintained, & an antiemetic may be prescribed; however, the initial action would be to turn the child to the side.

A child with a diagnosis of a hernia has been scheduled for a surgical repair in 2 weeks. The nurse reinforces instructions to the parents about the signs of possible hernial strangulation. The nurse tells the parents that which manifestation requires health care provider (HCP) notification by the parents?

Vomiting. Rationale: The parents of a child with a hernia need to be instructed about the signs or strangulation. These signs include vomiting, pain, & an irreducible mass. The parents should be instructed to contact the H.C.P. immediately if strangulation is suspected. Fever, diarrhea, & constipation are not associated with strangulation of a hernia.

A nurse is reinforcing discharge teaching with the parents of a preterm infant who has a prescription for home oxygen and pulse oximetry monitoring. Which of the following statements by the parents indicates a need for further teaching?

We will rotate the probe of the pulse oximeter every 24 hours. Rationale: Pulse oximeters are a noninvasive method of monitoring oxygen saturation (SaO2) of the blood. It is obtained by the application of a probe around the hand, foot, finger, toes, or earlobe, which is then connected to a machine that provides continuous oxygen saturation levels. The probe should be rotated every 3 to 4 hr to prevent pressure necrosis from occurring. Excessive movement, as well as heat and light, can interfere with the results. Due to the risk of oxygen toxicity, which is a particular concern with preterm infants, the parents should be instructed to notify the provider for consistent SaO2 readings over 95%. This may be an indication the infant is receiving too much oxygen and the amount should be decreased.

A nurse is reinforcing dietary teaching with the guardian of a school-age child who has celiac disease. Which of the following foods should the nurse recommend including in the child's diet?

White rice. Rationale: The nurse should reinforce to the guardian that celiac disease is a genetic autoimmune disorder in which eating gluten, even in very small amounts, can damage the child's small intestine. Currently, the only treatment for the disease is a lifelong, strict adherence to a gluten-free diet. The nurse should stress the importance of avoiding foods containing wheat, rye, barley, and oats. The child should consume foods that are gluten-free, such as milk, cheese, rice, corn, eggs, potatoes, fruits, vegetable, fresh poultry, meats, fish, and dried beans.

A nurse employed in an emergency department is instructed to monitor a child diagnosed with epiglottitis. The nurse notes that the child is leaning forward with the chin thrust out. The nurse interprets this finding as indicating:

An airway obstruction Rationale: Clinical manifestations suggestive of airway obstruction include tripod positioning (leaning forward supported by arms, chin thrust out, mouth open), nasal flaring, tachycardia, a high fever, and sore throat. The data in the question do not relate to options 1, 2, or 3.

An 18-month-old child is being discharged after surgical repair of hypospadias. Which postoperative nursing care measure should the nurse stress to the parents as they prepare to take this child home?

Avoid tub baths until the stent has been removed. Rationale: After hypospadias repair, the parents are instructed to avoid giving the child a tub bath until the stent has been removed to prevent infection. Diapers are placed on the child to prevent the contamination of the surgical site. Toilet training should not be an issue during this stressful period. Fluids should be encouraged to maintain hydration.

The nurse collects a urine specimen preoperatively from a child with epispadias who is scheduled for surgical repair. The nurse reviews the child's record for the laboratory results of the urine test & would most likely expect to note which finding?

Bacteriuria. Rationale: Epispadias is a congenital defect that involves the abnormal placement of the urethral orifice of the penis. In clients with this condition, the urethral opening is located anywhere on the dorsum of the penis. This anatomical characteristic leads to the easy access of bacterial entry into the urine.

A nurse is caring for a child with a diagnosis of intussusception. Which of the following symptoms would the nurse expect to note in this child?

Blood and mucus in the stools Rationale: The child with intussusception classically presents with severe abdominal pain that is crampy and intermittent and that causes the child to draw in his or her knees to the chest. Vomiting may be present, but it is not projectile. Bright red blood and mucus are passed through the rectum and commonly described as currant jelly-like stools. Ribbon-like stools are not a manifestation of this disorder.

The nurse reinforces instructions to the mother about dietary measures for a 5-year-old child with lactose intolerance. The nurse should tell the mother that which supplement will be required as a result of the need to avoid lactose in the diet?

Calcium. Rationale: Lactose intolerance is the inability to tolerate lactose, which is the sugar that is found in dairy products. Removing milk from the diet can provide relief from symptoms. Additional dietary changes may be required to provide adequate sources or calcium &, if the child is an infant, protein & calories.

The nurse is assisting to develop a plan of care for a child who is at risk for seizures. Which interventions apply if the child has a seizure? Select all that apply.

1. Time the seizure. 2. Stay with the child. 3. Move furniture away from the child. Rationale: During a seizure, the child is placed on his or her side in the lateral position. This type of positioning will prevent aspiration because saliva will drain out of the corner of the child's mouth. The child is not restrained because this could cause injury. The nurse would loosen clothing around the child's neck & ensure a patent airway. Nothing is placed into the child's mouth during a seizure because this action may cause injury to the child's mouth, gums, or teeth. The nurse would stay with the child to reduce the risk of injury & to allow for the observation & timing of the seizure.

A nurse is monitoring for signs of dehydration in a 1-year-old child who has been hospitalized for diarrhea and prepares to take the child's temperature. Which method of temperature measurement should be avoided?

Rectal Rationale: Rectal temperature measurements should be avoided if diarrhea is present. The use of a rectal thermometer can stimulate peristalsis and cause more diarrhea. Axillary or tympanic measurements of temperature would be acceptable. Most measurements are performed via electronic devices.

The nursing instructor asks a nursing student about phenylketonuria (PKU). Which statement made by the student indicates an understanding of this disorder?

"All 50 states require routine screening of all newborns for P.K.U." Rationale: P.K.U. is an autosomal-recessive disorder. Treatment includes the dietary restriction of phenylalanine intake (not tyramine intake). P.K.U. is a genetic disorder that results in central nervous system (CNS) damage from toxic levels of phenylalanine in the blood.

The nurse is teaching a group of female adolescents about toxic shock syndrome and the use of tampons. What statement by a participant indicates a need for additional teaching?

"I can use a superabsorbent tampon for more than 6 hours." Rationale: Teaching female adolescents about the association between toxic shock syndrome and the use of tampons is important. The teaching should include not using superabsorbent tampons; not leaving the tampon in for longer than 4 to 6 hours; alternating the use of tampons with sanitary napkins; washing hands before inserting a tampon to decrease the chance of introducing pathogens; and informing a health care provider if a sudden high fever, vomiting, muscle pain, dizziness, or a rash that looks like a sunburn appears.

A patient who has asthma is scheduled to start taking a glucocorticoid medication with a metered-dose inhaler (MDI) with a hydrofluoroalkane (HFA) propellant. A nurse should give which of these instructions regarding correct use of the inhaler?

"Rinse the mouth after each dose administration". Rationale: Rinsing the mouth after administration is important for inhaled glucocorticoids to avoid candidiasis. Glucocorticoid inhalers are used for long-term prophylaxis of asthma, not for symptomatic relief. When two puffs are needed, an interval of at least 1 minute should separate the first puff from the second. Inhaling through the mouth just before activating the MDI is the proper technique for its use. Spacers are available for use with MDIs to avoid swallowing the dose and to allow for maximum delivery of medication to the lungs; this is not necessary with hydrofluoroalkane (HFA) propellants.

A nurse is providing information to the mother of a child with nephrotic syndrome regarding the edematous appearance of the child. Which of the following statements should the nurse make to the mother?

"The fluid retention should be controlled by medication and diet." Rationale: Most children experience remission with treatment and corticosteroids. Diuretics also may be a component of the treatment plan, and a restricted sodium diet is recommended. It is important to give the parent information in a matter-of-fact manner and address the issue that is the parent's concern. Options 1, 2, and 4 are inaccurate and inappropriate statements to the mother.

A nurse is instructing a nursing assistant on techniques to facilitate lipreading with a hearing-impaired child who lip-reads. Which techniques should the nurse include (select all that apply)?

1. Speak at eye level. 2. Keep sentences short. 3. Use facial expressions while speaking. Rationale: To facilitate lipreading for a hearing-impaired child who can lip-read, the speaker should be at eye level, facing the child directly or at a 45-degree angle. Facial expressions should be used to assist in conveying messages, and the sentences should be kept short. The speaker should stand close to the child, not at a distance. Using a loud tone while speaking will not facilitate lipreading.

Which nursing actions are appropriate when providing care to a pediatric client who has sustained a smoke-inhalation injury? Select all that apply.

1. Assessing for respiratory distress 2. Auscultating the lungs for wheezing 3. Providing support to the family Rationale: A pediatric client who sustained a smoke-inhalation injury is at risk for respiratory distress; therefore, it is appropriate for the nurse to assess this patient for clinical manifestations associated with the phenomenon. Crackles and wheezing are both complications associated with a smoke-inhalation injury. The nurse should provide support to the family of a pediatric client who sustained a smoke-inhalation injury.

The nurse is assigned to care for a child who is scheduled for an appendectomy. Which prescriptions does the nurse anticipate to be prescribed? Select all that apply.

1. Initiate an intravenous line. 2. Maintain nothing-by-mouth status. 3. Administer intravenous antibiotics. 4. Administer preoperative medications. Rationale: During the preoperative period, enemas or laxatives should not be administered. In addition, heat should not be applied to the abdomen. Any of these interventions can cause the rupture of the appendix & reluctant peritonitis. Intravenous fluids would be started, & the child should receive nothing by mouth while awaiting surgery. Antibiotics are usually administered because of the risk of perforation. Preoperative medications are administered as prescribed.

An important nursing consideration when caring for a 10-month-old infant with respiratory syncytial virus (RSV)/bronchiolitis would be which of the following?

Encourage to drink 8 ounces of formula every 4 hours. Rationale: Hydration is very important in children with RSV bronchiolitis to loosen secretions and prevent shock.

A nurse is instructing the mother of a child with cystic fibrosis (CF) about the appropriate dietary measures. Which of the following meals best illustrates the most appropriate diet for a client with cystic fibrosis?

A piece of fried chicken and a loaded baked potato Rationale: Children with CF are managed with a high-calorie, high-protein diet. Pancreatic enzyme replacement therapy is undertaken, and fat-soluble vitamin supplements are administered. Fats are not restricted unless steatorrhea cannot be controlled by increased levels of pancreatic enzymes. A piece of fried chicken and a loaded baked potato provides a high-calorie and high-protein meal that includes fat.

A client has a prescription for continuous monitoring of oxygen saturation by pulse oximetry. The nurse performs which best action to ensure accurate readings on the oximeter?

Ask the client to limit motion in the hand attached to the pulse oximeter. Rationale: Several factors can interfere with the reading of accurate oxygen saturation levels on a pulse oximeter. To ensure accurate readings, the nurse should ask the client to limit motion of the area attached to the sensor. The nurse should apply the device to a warm area because hypotension, hypothermia, and vasoconstriction interfere with blood flow to the area. If possible, the nurse should avoid placing the sensor distal to any invasive arterial or venous catheters, pressure dressings, or blood pressure cuffs. The nurse needs to know that very dark nail polish (black, brown-red, blue, green) interferes with accurate measurement.

A nurse in an emergency department is assessing an infant who has laryngotracheobronchitis. Which of the following findings should the nurse report and an indication of impending airway obstruction?

Nasal flaring Rationale: Acute laryngotracheobronchitis (croup) causes dyspnea and swelling of the upper airway. Indications of impending airway instruction include tachycardia, tachypnea, increased restlessness, flaring nares, and intercostal retractions.

What sign is indicative of respiratory distress in infants?

Nasal flaring Rationale: Infants have difficulty breathing through their mouths; therefore nasal flaring is usually accompanied by extra respiratory efforts. It also allows more air to enter the nares flare.

A nurse has provided dietary instructions to the mother of a child with celiac disease. The nurse determines that further instructions are needed if the mother states that she will include which of the following in the child's nutritional plan?

Oatmeal Rationale: Dietary management is the mainstay of treatment for the child with celiac disease. All wheat, rye, barley, and oats should be eliminated from the diet and replaced with corn and rice. Vitamin supplements, especially fat-soluble vitamins and folate, may be needed in the early period of treatment to correct deficiencies.

A child has been diagnosed with Reye's syndrome. The nurse understands that a major symptom associated with Reye's syndrome is:

Persistent vomiting Rationale: Persistent vomiting is a major symptom that is associated with increased intracranial pressure (ICP). Options 2, 3, and 4 are incorrect. Protein is not present in the urine. Reye's syndrome is related to a history of viral infections, and hypoglycemia is a symptom of this disease.

A nurse is reviewing the record of a child with a diagnosis of pyloric stenosis. Which data would the nurse expect to note as having been documented in the child's record?

Projectile vomiting Rationale: Clinical manifestations of pyloric stenosis include projectile, nonbilious vomiting; irritability; hunger and crying; constipation; and signs of dehydration, including a decrease in urine output.

After a tonsillectomy, a child is brought to the pediatric unit. The nurse places the child in which appropriate position?

Prone Rationale: The child should be placed in a prone or side-lying position after tonsillectomy to facilitate drainage. Options 2, 3, and 4 will not achieve this goal.

What will be the nurse's next action after noting dimpling and a tuft of hair located in the lumbosacral area of the preschool child during the examination?

Record and refer the finding for follow-up to the pediatrician Rationale: Dimpling and hair growth may signal spina bifida occulta, which usually is benign. However, some complications can be associated, and further investigation is warranted to prevent possible damage to the spinal cord. Magnetic resonance imaging (MRI) is often the diagnostic tool used. No hygienic concerns need prevail. These findings do not suggest development of precocious puberty or any other hormonal problem. The dimpling and hair tuft must be clearly explained to the parents.

A nurse is assisting in developing a plan of care for a child who will be returning from the operating room following a tonsillectomy. The nurse plans to place the child in which position on return from the operating room?

Side-lying Rationale: The child should be placed in a prone or side-lying position following tonsillectomy to facilitate drainage. Options 2, 3, and 4 will not facilitate drainage.

A day care nurse is observing a 2-year-old child and suspects that the child may have strabismus. Which of the following observations may be indicative of this condition?

The child consistently tilts his or her head to see. Rationale: The nurse may suspect strabismus in a child when the child complains of frequent headaches, squints, or tilts the head to see. Options 1, 2, and 4 are not indicative of this condition.

The nurse is working in the emergency department & is caring for a child who has been diagnosed with epiglottitis. Which is an indication that the child may be experiencing airway obstruction?

The child thrusts the chin forward & opens the mouth. Rationale: Clinical manifestations that are suggestive of airway obstruction include tripod positioning (leaning forward supported by the hands & arms with the chin thrust out & the mouth open), nasal flaring, tachycardia, a high fever, & a sore throat.

The nurse in the newborn nursery is preparing to feed a newborn the first feeding of sterile water. During the feeding, the newborn suddenly begins to cough, choke, and become cyanotic. Based on these symptoms, the nurse might suspect that the newborn has which of the following conditions?

Tracheoesophageal fistula Rationale: The first feeding a newborn receives is sterm-24terile water to assess whether the newborn might have one of the tracheoesophageal (TE) conditions. Although sterile water is more easily absorbed and causes less aspiration than formula, the newborn with a suspected TE fistula condition will cough and choke during feedings. These symptoms are not associated with the conditions noted in options 1, 3, or 4.

The nurse reinforces instructions to the mother of a child with croup about the measures to take if an acute spasmodic episode occurs. Which statement by the mother indicates the need for further teaching?

"I will place a steam vaporizer in my child's room." Rationale: Steam from warm running water in a closed bathroom & cool mist from a bedside humidifier are effective for reducing mucosal edema. Cool-mist humidifiers are recommended as compared with steam vaporizers, which present a danger of scalding burns. Taking the child out into the humid night air may also relieve mucosal swelling. Remember, however, that a cold mist may precipitate bronchospasm.

The parents of a newborn have been told that their child was born with bladder exstrophy, & the parents ask the nurse about this condition. Which response should the nurse give to the parents about bladder exstrophy?

"It is an extrusion of the urinary bladder to the outside of the body through a defect in the lower abdominal wall." Rationale: Bladder exstrophy is a congenital anomaly that is characterized by the extrusion of the urinary bladder to the outside of the body through a defect in the lower abdominal wall. The cause is unknown, & there is a higher incidence among males.

The nurse has provided instructions to the mother of a child who has been diagnosed with bacterial conjunctivitis. Which statement by the mother would indicate the need for further teaching?

"It is okay to share towels & washcloths." Rationale: Bacterial conjunctivitis is highly contagious, & infection control measures should be taught; these include frequent hand washing & not sharing towels & washcloths. Options 1, 2, & 4 are correct measures.

A child is admitted to the hospital with a probable diagnosis of nephrotic syndrome. Which findings would the nurse expect to observe? Select all that apply.

1. Pallor 2. Edema 3. Anorexia 4. Proteinuria Rationale: Nephrotic syndrome is a kidney disorder that is characterized by massive proteinuria, hypoalbuminemia, edema, elevated serum lipids, anorexia, and pallor. The urine volume is decreased, and the urine is dark and frothy in appearance. The child with this condition gains weight.

A 1-year-old child is admitted to the hospital for control of tonic-clonic seizures. The nurse would do which of the following in order to protect the child from injury? Select all that apply.

1. Remove toys that have bright, blinking lights on them. 2. Keep side rails and other hard objects padded. 3. Turn the client to the side during a seizure. Rationale: Attempting to place something in a child's mouth during a seizure is not helpful even if it is padded. The mouth is usually clenched, and one would have to use force to open the mouth.

A nurse is assisting with performing admission data collection on a 2-year-old child who has been diagnosed with nephrotic syndrome. The nurse collects data knowing that a common characteristic associated with nephrotic syndrome is:

Generalized edema Rationale: Nephrotic syndrome is defined as massive proteinuria, hypoalbuminemia, and edema. The urine is dark, foamy, and frothy, but microscopic hematuria may be present. Frank, bright red blood in the urine does not occur. Urine output is decreased, and the blood pressure is normal or slightly decreased.

The nurse is reviewing the health record of an infant with a diagnosis of gastroesophageal reflux. Which signs/symptoms of this disorder should the nurse expect to note documented in the record?

Hiccupping and spitting up after a meal Rationale: Clinical manifestations of all types of gastroesophageal reflux include vomiting (spitting up) after a meal, hiccupping, and recurrent otitis media related to pooled secretions in the nasopharynx during sleep.

The nurse is collecting data about a child who has been admitted to the hospital with a diagnosis of seizures. Which action would best assist in determining the cause of the seizure?

Obtaining a history regarding factors that may occur before the seizure activity. Rationale: Fever & infections increase the body's metabolic rate. This can cause seizure activity among children who are less than 5 years old. Dehydration & electrolyte imbalance can also contribute to the occurrence of a seizure. Falls can cause head injuries, which would increase intracranial pressure or cerebral edema. Some medications could cause seizures. Specific gravity would not be a reliable test because it varies, depending on the existing condition. Psychiatric illness has no impact on seizure occurrence or cause. Children do not remember what happened during the seizure itself.

A nurse is reinforcing teaching with an adolescent who has a new prescription for sulfamethoxazole-trimethoprim. Which of the following adverse effects should the nurse include in the teaching?

Photosensitivity. Rationale: sulfamethoxazole-trimethoprim has an AE of photosensitivity. Clients who take this medication should be taught to avoid direct sunlight.

After a tonsillectomy, which fluid or food item would be appropriate to offer to the child?

Yellow Jell-O. Rationale: After a tonsillectomy, cool liquids should be administered. Citrus, carbonated, & extremely hot or cold liquids need to be avoided because they may irritate the throat. Milk & milk products (pudding) are avoided because they coat the throat & cause the child to clear the throat, thus increasing the risk of bleeding. Red liquids need to be avoided because they give the appearance of blood if the child vomits.

A health care provider prescribes an intravenous (IV) solution of 5% dextrose and half-normal saline (0.45%) with 40 mEq of potassium chloride for a child with hypotonic dehydration. The nurse performs which priority assessment before administering this IV prescription?

Checks the amount of urine output Rationale: In hypotonic dehydration, electrolyte loss exceeds water loss. The priority assessment before administering potassium chloride intravenously would be to assess the status of the urine output. Potassium chloride should never be administered in the presence of oliguria or anuria. If the urine output is less than 1 to 2 mL/kg/hour, potassium chloride should not be administered.

A nurse reviews the record of an infant who is seen in the clinic. The nurse notes that a diagnosis of esophageal atresia with tracheoesophageal fistula (TEF) is suspected. The nurse expects to note which most likely clinical manifestation of this condition in the medical record?

Choking with feedings Rationale: Any child who exhibits the "3 Cs"—coughing and choking during feedings and unexplained cyanosis—should be suspected of having TEF. Options 1, 2, and 4 are not specifically associated with TEF.

The nurse is assigned to care for a child after a myringotomy with the insertion of tympanostomy tubes. The nurse notes a small amount of reddish drainage from the child's ear after the surgery. On the basis of this finding, which action should the nurse take?

Document the findings. Rationale: After a myringotomy with the insertion of tympanostomy tubes, the child is monitored for ear drainage. A small amount of reddish drainage is normal during the first few days after surgery. However, any heavy bleeding that occurs after 3 days should be reported. The nurse would document the findings. Options 2, 3, & 4 are not necessary.