A nurse is caring for a newborn who has an order for phototherapy to treat hyperbilirubinemia. Which of the following actions should the nurse take?

Rationale:

A. A client who has a firm fundus following a vaginal birth and reports continuous perineal pain of 8 on a scale of 0 to 10: Although the fundus is firm, severe continuous perineal pain may indicate complications such as hematoma or infection, requiring immediate assessment and intervention to prevent worsening condition.

B. A client who is 30 hr postpartum and reports feeling tearful and overwhelmed: Postpartum emotional lability is common in this timeframe and generally not an immediate safety concern. The nurse should provide support but this client’s condition is not urgent.

C. A client who is 12 hr postpartum and reports having to urinate frequently: Frequent urination postpartum may be due to diuresis or normal bladder function return and is not typically urgent unless accompanied by other signs of infection or retention.

D. A client who had a cesarean birth yesterday and reports burning incision pain of 5 on a scale of 0 to 10: Moderate incision pain is expected after surgery and can be managed with analgesics; it does not require immediate intervention compared to potential perineal complications.

Rationale:

A. Headaches with aura: Headaches accompanied by aura are a strong contraindication to oral contraceptive use due to the significantly increased risk of thromboembolic events, particularly ischemic stroke. Estrogen-containing contraceptives can further exacerbate this vascular risk, making alternative forms of birth control necessary.

B. Gastroesophageal reflux disease: GERD is a gastrointestinal condition that does not affect the safety or efficacy of oral contraceptives. Although hormonal fluctuations can sometimes influence gastric symptoms, GERD is not a contraindication to contraceptive use.

C. History of mononucleosis 1 year ago: A past infection with mononucleosis does not impact liver function long-term in most cases and does not interfere with hormonal contraceptive use. It does not pose any increased risk related to estrogen or progesterone components.

D. Irregular menstrual cycles: While irregular cycles are a common reason for initiating oral contraceptives, they are not a contraindication. In fact, hormonal contraceptives are often used therapeutically to regulate menstrual patterns and reduce cycle variability.