The nurse should first address the client’s

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followed by the client’s

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.

Choice A rationale

Scant lochia rubra with a few small clots is a normal finding at 2 days postpartum. Lochia rubra, which is dark red discharge, is expected during the first 3-4 days. Scant bleeding and small clots are considered normal and indicate the uterine healing process is progressing appropriately. Excessive bleeding or large clots would be cause for concern.

Choice B rationale

Bilateral ankle edema is a common and expected finding at 2 days postpartum. This is due to the mobilization of fluid retained during pregnancy and the effects of gravity. While it should be monitored, it typically resolves on its own. The nurse should assess for other signs of a more serious condition, such as unilateral leg swelling, pain, or redness, which could indicate a deep vein thrombosis.

Choice C rationale

A urine output of 2,500 mL/day is within the expected range for a postpartum client. Diuresis is a normal physiological process during the first few days after birth, as the body eliminates the excess fluid volume accumulated during pregnancy. Urine output typically ranges from 2,000 to 3,000 mL/day, indicating adequate kidney function and fluid mobilization.

Choice D rationale

Deep-tendon reflexes of 4+ are a hyperreflexic finding that can indicate a neurological complication, such as preeclampsia. Normal deep-tendon reflexes are typically 1+ to 2+. Hyperreflexia is a sign of central nervous system irritability and can precede seizure activity, making it a critical finding that requires immediate reporting to the provider for further assessment and intervention. .

Choice A rationale

Varying a child's scheduled activities each day is counterproductive for a child with ADHD. Children with this condition benefit significantly from structured routines and predictable schedules. A consistent daily structure minimizes the need for the child to process new information and adapt to changes, which can be overwhelming and lead to decreased concentration and increased impulsivity.

Choice B rationale

Encouraging a child with ADHD to read a book during an outdoor school activity period is not a suitable strategy. This situation places the child in an environment filled with external stimuli, such as other children playing, sounds, and visual distractions. This highly stimulating setting is precisely the opposite of what is needed to improve focus and attention in a child with ADHD.

Choice C rationale

Children with ADHD have difficulty filtering out irrelevant stimuli from their environment. Providing a designated, quiet space with minimal distractions directly addresses this core challenge. This environment reduces the number of competing sensory inputs, allowing the child to direct their limited attention resources more effectively toward a single task, such as homework, thereby improving concentration.

Choice D rationale

The mode of completing homework, whether by hand or using a computer, is less critical than the environmental context. While a computer might offer some interactive benefits, it also presents numerous potential distractions, such as internet access, games, and notifications. Having a child write by hand in a distracting environment would not be as effective as using a computer in a distraction-free zone. *.