A nurse is caring for a newborn 4 hr after birth. Which of the following actions should the nurse include in the plan of care to prevent jaundice?

A) Notify the client's provider:

There is no indication to notify the provider at this time. The presence of lochia rubra with small clots and a firm, midline fundus at the umbilicus indicates typical postpartum bleeding and uterine involution. This finding does not warrant immediate notification of the provider.

B) Encourage the client to empty her bladder:

Encouraging the client to empty her bladder is essential for promoting uterine contractions and preventing uterine atony. However, in this scenario, the fundus is already midline and firm, suggesting that bladder distension is not the cause of the excessive bleeding. While voiding may help, it is not the priority action.

C) Increase the frequency of fundal massage:

Increasing the frequency of fundal massage may not be necessary in this situation since the fundus is already midline and firm, indicating adequate uterine contractions. Fundal massage is typically performed if the fundus is boggy or if there is excessive bleeding.

D) Document the findings and continue to monitor the client:

This is the correct action. Documenting the assessment findings, including the amount and character of lochia, presence of clots, and fundal height, is essential for ongoing monitoring and evaluation of the client's postpartum recovery. Continuing to monitor the client allows the nurse to detect any changes in condition that may require further intervention.

A) Educate parents on blood glucose monitoring:

Blood glucose monitoring is not directly related to the care of a newborn with phenylketonuria (PKU). PKU is a metabolic disorder that affects the body's ability to process phenylalanine, an amino acid found in protein. Therefore, educating parents on blood glucose monitoring is not relevant to the management of PKU.

B) Obtain a blood sample for blood type:

Obtaining a blood sample for blood type is a routine procedure performed shortly after birth to determine the newborn's blood type and Rh factor. While this is an important aspect of newborn care, it is not specific to the management of PKU.

C) Administer thyroid hormone replacement:

Administering thyroid hormone replacement is not indicated for a newborn with PKU. PKU is a metabolic disorder caused by a deficiency of the enzyme phenylalanine hydroxylase, which leads to the accumulation of phenylalanine in the body. Thyroid hormone replacement is used to treat hypothyroidism, a condition involving an underactive thyroid gland, and is not related to PKU management.

D) Initiate a controlled low-protein diet:

Initiating a controlled low-protein diet is a crucial aspect of managing PKU. Since PKU is characterized by the inability to metabolize phenylalanine properly, dietary management aims to limit phenylalanine intake by implementing a low-protein diet. This diet helps prevent the accumulation of phenylalanine in the body, reducing the risk of neurological damage and other complications associated with PKU. Therefore, including this action in the plan of care is essential for effectively managing PKU in the newborn.