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) Call the provider to further assess the newborn:

An apical heart rate of 130/min in a newborn is within the expected range, so there is no need to call the provider for further assessment. This heart rate is considered normal for a newborn.

B) Document this as an expected finding:

This is the correct action. A heart rate of 130/min is within the expected range for a newborn. Documenting the finding as expected ensures accurate documentation of the newborn's vital signs.

C) Ask another nurse to verify the heart rate:

There is no need to ask another nurse to verify the heart rate since 130/min is a normal finding in a newborn. This would unnecessarily delay documentation and could potentially cause confusion.

D) Prepare the newborn for transport to the NICU:

There is no indication for transport to the NICU based solely on an apical heart rate of 130/min. This heart rate is within the normal range for a newborn, and there are no signs of distress or other complications that would necessitate NICU admission.

A) Wash the cord daily with mild soap and water:

This instruction is incorrect. Washing the umbilical cord stump daily with soap and water can increase the risk of infection and delay the drying process. It is recommended to keep the cord stump clean and dry without using soap or other cleansing agents.

B) Give a sponge bath until the cord stump falls off:

This instruction is correct. Until the umbilical cord stump falls off, it is advisable to give the newborn sponge baths rather than immersing them in a tub of water. Sponge baths help keep the cord stump dry and reduce the risk of infection until it naturally separates from the baby's body.

C) Cover the cord with the diaper:

This instruction is incorrect. Covering the umbilical cord stump with a diaper can create a moist environment, which may increase the risk of infection. It is recommended to fold down the top edge of the diaper to expose the cord stump to air and aid in drying.

D) Apply petroleum jelly to the cord stump:

This instruction is not recommended. Applying petroleum jelly or any other substance to the umbilical cord stump can interfere with the drying process and increase the risk of infection. It is best to allow the cord stump to air dry naturally without the use of additional products.