A nurse is caring for a 2-year-old child who has Clostridium difficile.
Which of the following actions should the nurse take?

The correct answers are C and D.

Choice A reason: Preferred bath time is a personal preference and comfort-related aspect of patient care. While it is important for overall patient satisfaction and care planning, it is not critical information for a change-of-shift report following a total knee arthroscopy. The focus in such reports is typically on clinical status, immediate care needs, and potential complications.

Choice B reason: Admission vital signs are the initial measurements taken upon the patient’s admission to the healthcare facility. These are baseline values that can be referenced later to note any significant changes. However, for a change-of-shift report, especially 2 days postoperative, the most current vital signs and any changes since surgery are more pertinent than the admission values.

Choice C reason: The time of the last pain medication is crucial information for a change-of-shift report. Pain management is a key aspect of postoperative care, particularly after procedures like total knee arthroscopy. Knowing when the last dose was administered helps the incoming nurse manage the patient’s pain effectively and anticipate when the next dose is due.

Choice D reason: The steps required for dressing change are essential to include in the change-of-shift report. Proper wound care and dressing changes are vital to prevent infection and ensure proper healing after surgery. Detailed instructions on the dressing change process help maintain consistency in care between different caregivers.

Choice A rationale:

Hegar's sign is a softening of the uterine isthmus, which occurs during early pregnancy. It is not related to changes in the color of the vagina and vulva.

Choice B rationale:

Chloasma refers to the appearance of dark, blotchy, and hyperpigmented skin patches that can occur during pregnancy, primarily on the face. It is not related to changes in the color of the vagina and vulva.

Choice C rationale:

Ballottement is a technique used during a physical examination to assess for a floating fetus within the amniotic fluid. It is not related to changes in the color of the vagina and vulva.

Choice D rationale:

Chadwick's sign is the purplish or bluish discoloration of the vaginal and vulvar mucosa that can occur during pregnancy. This sign is due to increased blood flow to the area, which is a normal physiological change in pregnancy.