A nurse is assisting in the initiation of phototherapy.
Which nursing action is indicated for the newborn?

Choice A rationale

Applying warm, moist packs is generally used to promote circulation and relieve discomfort associated with an already-formed thrombus or thrombophlebitis, not as a primary prophylactic measure. Prevention centers on enhancing venous return and inhibiting clot formation, whereas heat application may slightly increase local vasodilation and is not the most effective primary preventative method in the immediate postpartum period.

Choice B rationale

Elastic stockings (anti-embolism stockings) apply external graduated compression to the legs. This compression aids in increasing the velocity of venous blood flow and reducing venous stasis, particularly in the lower extremities, thereby reducing the risk of Deep Vein Thrombosis (DVT) and subsequent thrombophlebitis, especially important when the client is at rest or in bed.

Choice C rationale

Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen are used primarily for pain management and reducing inflammation. While some NSAIDs possess mild antiplatelet effects, this is not their primary indication, nor is it a sufficiently robust measure to be considered a key intervention for preventing thrombophlebitis in the postpartum period, which necessitates focused mechanical or pharmacological prophylaxis.

Choice D rationale

Ambulation is crucial as it promotes muscle contraction of the lower extremities (the skeletal muscle pump), which mechanically compresses the deep veins and forces blood back toward the heart. This action significantly increases venous return, prevents venous stasis, and activates endogenous fibrinolysis, making early and frequent ambulation a cornerstone of thrombophlebitis prevention.

Choice A rationale

The proper sequence for suctioning a newborn is the mouth first, then the nose, to prevent the newborn from aspirating secretions. Suctioning the nose first may cause the newborn to gasp, drawing pharyngeal secretions into the trachea and lungs, potentially leading to aspiration pneumonia or respiratory distress.

Choice B rationale

Depressing the bulb prior to insertion into the mouth or nose creates a negative pressure inside the bulb. Releasing the pressure after insertion will then effectively draw secretions into the bulb, achieving optimal suction. Inserting a non-depressed bulb will be ineffective for removing secretions.

Choice C rationale

The bulb syringe does not require lubrication with sterile water before use; it is intended for immediate use as a mechanical suction device. Lubrication could potentially introduce excess fluid into the newborn's airway or dilute secretions, which does not enhance the device's primary function of removing mucus.

Choice D rationale

The bulb should be placed gently into the sides of the newborn's mouth, rather than the center, to avoid stimulating the gag reflex. Placing it at the sides directs suction toward the cheeks and gums, facilitating the removal of secretions from the oral cavity without causing discomfort or vomiting.