A nurse is caring for a client who is 12 hours postpartum and has an episiotomy.
Which of the following actions should the nurse take?

Choice A rationale

Transcutaneous electrical nerve stimulation (TENS) is primarily used during the first and second stages of labor to manage discomfort by interfering with pain signal transmission through nerve stimulation. Its effectiveness significantly diminishes in the third stage, which involves the expulsion of the placenta, as the pain sensation during this stage is distinct and less responsive to superficial nerve modulation.

Choice B rationale

Gestational diabetes itself is not a contraindication for TENS use. TENS therapy works by stimulating sensory nerves to block pain signals or release endorphins. The metabolic changes associated with gestational diabetes do not interfere with the biophysical mechanisms by which TENS alleviates pain, making it a safe option for pain management in this population.

Choice C rationale

Increasing TENS intensity during a contraction aligns with the physiological response to labor pain. As uterine contractions intensify, the perceived pain increases. Manually adjusting the TENS unit's intensity during a contraction allows for a dynamic and responsive pain management strategy, providing greater counter-stimulation when the pain is at its peak, enhancing its efficacy.

Choice D rationale

TENS does not eliminate pain during a contraction but rather reduces its perception. It works by activating large diameter afferent nerve fibers, which inhibits the transmission of nociceptive signals via the gate control theory of pain. It also may stimulate the release of endogenous opioids, modulating pain pathways, leading to a reduction in pain intensity, not complete abolition.

Choice A rationale: Rechecking the newborn’s temperature is essential because the earlier reading of 36.3°C (97.3°F) was below the normal range of 36.5–37.5°C. Hypothermia in neonates can exacerbate hypoglycemia by increasing metabolic demands. Monitoring temperature ensures thermoregulation is maintained, which is critical for stabilizing glucose levels and preventing further complications in the early neonatal period.

Choice B rationale: Scheduling a lactation consult is appropriate due to the newborn’s initial difficulty latching. Effective breastfeeding is crucial for maintaining adequate glucose levels, especially in a macrosomic infant at risk for hypoglycemia. A lactation consultant can assess latch technique, feeding cues, and milk transfer to ensure the newborn receives sufficient nutrition and to support maternal confidence and bonding.

Choice C rationale: Rechecking the glucose level is warranted because the newborn previously had a hypoglycemic reading of 35 mg/dL, followed by a borderline normal value of 50 mg/dL. Continued monitoring is necessary to ensure glucose stability, especially in a macrosomic infant who may have persistent hyperinsulinemia. Serial glucose checks help detect recurrent hypoglycemia and guide further interventions.

Choice D rationale: Reinforcing hourly breastfeeding is not evidence-based and may lead to feeding fatigue for both the newborn and parent. Newborns typically feed every 2 to 3 hours. Overfeeding attempts can cause stress and interfere with effective feeding. Instead, feeding should be based on hunger cues and guided by lactation support to ensure quality rather than quantity of feeds.

Choice E rationale: Ensuring the newborn is tightly swaddled helps maintain body temperature and provides a calming, secure environment. Swaddling reduces energy expenditure, which is important in preventing further glucose depletion. It also helps soothe jitteriness and supports neuromuscular tone, both of which are affected in hypoglycemic states. Proper swaddling is a key nonpharmacologic intervention in neonatal care.

Choice F rationale: Encouraging skin-to-skin contact promotes thermoregulation, stabilizes glucose levels, and enhances breastfeeding success. This practice stimulates oxytocin release, improves maternal-infant bonding, and reduces stress responses in the newborn. For infants at risk of hypoglycemia, skin-to-skin contact is a first-line supportive measure that complements nutritional and metabolic interventions.

Choice G rationale: Maintaining an intravenous catheter for glucose administration is not indicated at this time. The newborn’s glucose level improved to 50 mg/dL after feeding, and the infant is now stable, alert, and feeding. IV glucose is reserved for symptomatic hypoglycemia unresponsive to feeding or when glucose levels remain critically low. In this case, noninvasive measures are sufficient.