A nurse is assessing a newborn following a forceps-assisted birth.
Which of the following clinical manifestations should the nurse identify as a complication of this birth method?

Choice A rationale
Providing oxygen to the client via a nonrebreather face mask is important if the client shows signs of hypoxia or shock due to blood loss. However, it is not the first action the nurse should take.
Choice B rationale
Administering oxytocin to the client can help contract the uterus and control bleeding, but it is not the first action the nurse should take.
Choice C rationale

Emptying the client’s bladder can help the uterus contract more effectively, but it is not the first action the nurse should take.
Choice D rationale
The first action the nurse should take when noting excessive vaginal bleeding is to massage the client’s fundus. A boggy uterus can lead to excessive bleeding, and massaging the fundus helps the uterus contract and can control the bleeding.

Choice A rationale
The nurse should close the newborn’s eyes before applying eyepatches. This is because the intense light used in phototherapy can harm the newborn’s eyes. Therefore, protective eye patches are used to shield the newborn’s eyes from the light while allowing the rest of the body to be exposed to the light. This helps to convert the bilirubin in the skin into a form that can be easily eliminated from the body.
Choice B rationale
Turning the newborn every 4 hours is not specifically related to phototherapy. While turning is important for preventing pressure ulcers, it does not directly impact the effectiveness of phototherapy. The primary goal of phototherapy is to expose as much of the newborn’s skin as possible to the light, which helps to reduce the level of bilirubin.
Choice C rationale
Applying hydrating lotion to the newborn’s skin prior to treatment is not recommended. The use of lotions or creams can block the light and reduce the effectiveness of phototherapy. The skin should be clean and free of any barriers to light penetration.
Choice D rationale
Providing the newborn with 15 mL glucose water after each feeding is not directly related to phototherapy. While maintaining hydration is important for all newborns, it does not specifically enhance the effectiveness of phototherapy for jaundice.