A nurse is assisting in the discharge planning of an infant who has a spica cast. Which of the following equipment needs should the nurse identify for discharge?

• Respiratory findings: The client has a history of asthma and now presents with slight inspiratory wheezes. Although respiratory rate and oxygen saturation are normal, wheezing indicates airway narrowing, which could worsen rapidly and needs prompt follow-up to prevent an acute asthma exacerbation.
• Menstrual period: The client's menstrual period is late by two weeks, but in itself, a late period does not require immediate intervention. It is an important clinical detail but does not demand urgent follow-up unless accompanied by unstable vital signs or other concerning symptoms.
• Vaginal spotting: Scant dark red spotting in a client with a late menstrual period raises concern for an ectopic pregnancy, which can be life-threatening if it ruptures. Spotting, combined with abdominal tenderness and delayed menses, demands immediate evaluation to rule out ectopic pregnancy or miscarriage.
• Oxygen saturation: The oxygen saturation of 97% on room air is within the normal range for a healthy adult. There is no evidence of hypoxemia, so this finding does not require immediate follow-up despite the client’s mild wheezing.
• Heart rate: The heart rate of 90/min is normal and within expected limits for adults. Although the client appears anxious, the heart rate itself does not indicate hemodynamic instability and does not require immediate intervention.
• Temperature: A temperature of 37.3° C (99.1° F) is within the normal range and does not suggest active infection or systemic illness. There is no immediate concern based solely on the client’s current temperature reading.
• Bowel sounds: Hyperactive bowel sounds can be associated with various conditions, including gastroenteritis, early bowel obstruction, or anxiety. While they contribute to the overall clinical picture of abdominal discomfort, they do not, on their own, necessitate immediate follow-up .
• Abdominal findings: Right lower quadrant abdominal tenderness, especially in combination with spotting and late menses, is concerning for an ectopic pregnancy. The possibility of rupture or hemorrhage makes abdominal tenderness a critical finding that requires urgent evaluation.

A. "I will empty the pouch every 2 to 3 hours.": While it is important to empty the pouch when it is about one-third to half full, emptying it every 2 to 3 hours is unnecessary unless output is extremely high. Frequent emptying is based on the volume of stool, not strict timing.

B. "I will no longer be able to eat nuts.": Clients with a sigmoid colostomy typically resume a normal diet after healing, including nuts, unless otherwise instructed. Nuts are more commonly restricted after ileostomies due to the risk of obstruction, not sigmoid colostomies.

C. "I should expect my stool to be unformed.": Stool from a sigmoid colostomy is usually formed or semi-formed because it comes from the end of the colon where water absorption has mostly occurred. Unformed stool is more characteristic of ileostomies.

D. "I will notify my doctor if the stoma starts to look purple.": A healthy stoma should appear pink to red and moist. A purple, dark, or dusky stoma indicates impaired blood flow or ischemia and requires immediate medical evaluation to prevent serious complications.