An adolescent patient at 20 weeks gestation states that it is important not to have a baby that weighs too much. She states this has been her rationale for limiting calories. Her weight has decreased from 110 pounds to 106 pounds.
What would be the best nursing response? Select one:

Choice A Reason: Applying Vaseline or lotion to newborn to maximize light absorption. This is an incorrect answer that indicates a contraindicated and harmful intervention that can interfere with phototherapy. Applying Vaseline or lotion to newborn can create a barrier or a reflective surface that can reduce the exposure and penetration of light to the skin, which can decrease the efficacy of phototherapy. Applying Vaseline or lotion to newborn can also cause skin irritation, infection, or burns, as it can trap heat and moisture under the light source.

Choice B Reason: Reducing the amount of fluid intake to 8 ounces daily. This is an incorrect answer that suggests a detrimental and dangerous intervention that can impair phototherapy. Reducing the amount of fluid intake to 8 ounces daily can cause dehydration, hypoglycemia, or electrolyte imbalance in newborns, which can worsen jaundice and increase the risk of complications such as kernicterus (brain damage due to high bilirubin levels). Reducing the amount of fluid intake to 8 ounces daily can also decrease the excretion of bilirubin through urine or stool, which can counteract the effect of phototherapy.

Choice C Reason: Keeping the newborn in the supine position. This is an incorrect answer that implies an incomplete and inadequate intervention that can limit phototherapy. Keeping the newborn in the supine position is a nursing action that involves placing the newborn on their back, which can expose their anterior body surface to light.

However, keeping the newborn in the supine position alone is not sufficient for phototherapy, as it does not expose their posterior body surface to light. The nurse should also reposition the newborn frequently to expose different body parts to light, such as their sides or abdomen.

Choice D Reason: Feeding every 3 hours to maximize intake of fluids and output. This is because feeding every 3 hours is a nursing intervention that can enhance the effectiveness and safety of phototherapy, which is a treatment that uses blue or white light to reduce the level of bilirubin in the blood. Bilirubin is a yellow pigment that is produced when red blood cells are broken down, which can cause jaundice (yellowish discoloration of the skin and mucous membranes) if it accumulates in excess. Phototherapy works by converting bilirubin into a water-soluble form that can be excreted through urine or stool. Feeding every 3 hours can increase the intake of fluids and calories, which can promote hydration, nutrition, and elimination of bilirubin.

Choice A Reason: Frequent voiding encourages sphincter control. This is an incorrect statement that has no relevance to labor and delivery. Sphincter control refers to the ability to contract and relax the muscles that control urination and defecation. It is not affected by frequent voiding.

Choice B Reason: A full bladder impedes oxygen flow to the fetus. This is an incorrect statement that confuses a full bladder with a prolapsed cord. A prolapsed cord is a condition where the umbilical cord slips through the cervix before the baby and becomes compressed by the fetal head, which can reduce oxygen flow to the fetus. A full bladder does not affect oxygen flow to the fetus.

Choice C Reason: Frequent voiding prevents bruising of the bladder. This is an incorrect statement that exaggerates the effect of a full bladder on the bladder wall. A full bladder may cause some pressure or discomfort on the bladder, but it does not cause bruising or damage.

Choice D Reason: A full bladder can impede fetal descent. This is a correct statement that explains why it is important for the nurse to assess the bladder regularly and encourage the laboring client to void every 2 hours.