Exhibits

A nurse on the labor and delivery unit is continuing to assist in the care of a newborn. Complete the following sentence by using the lists of options. Because the newborn is exhibiting

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the nurse should plan to

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.

Choice A rationale: Frequent breastfeeding every 2 hours enhances bilirubin excretion by promoting hydration and stooling. Bilirubin is eliminated via feces, and increased feeding stimulates gastrointestinal motility. Breast milk also supports hepatic conjugation of bilirubin. In late preterm infants, feeding cues may be subtle, so scheduled waking ensures intake adequacy. This intervention is critical in managing hyperbilirubinemia conservatively and preventing escalation to invasive treatments such as exchange transfusion.

Choice B rationale: Sterile water lacks calories and nutrients, and does not promote bilirubin excretion. It may dilute serum sodium and increase the risk of water intoxication. Newborns require energy-dense feeds to support hepatic function and bowel activity. Supplementation with sterile water is contraindicated in hyperbilirubinemia management. Instead, formula or breast milk should be used to ensure adequate caloric intake and hydration, both of which are essential for bilirubin clearance.

Choice C rationale: Blood cultures are indicated when sepsis is suspected. In this case, the newborn is afebrile, vigorous, and has stable vital signs. Hyperbilirubinemia alone does not warrant blood cultures unless accompanied by signs of infection such as temperature instability, lethargy, or poor perfusion. The absence of systemic symptoms and a known cause (birth trauma, prematurity) makes sepsis unlikely. Therefore, blood cultures are not anticipated at this stage.

Choice D rationale: Exchange transfusion is reserved for severe hyperbilirubinemia unresponsive to phototherapy or when bilirubin levels approach neurotoxic thresholds. The American Academy of Pediatrics recommends exchange transfusion when bilirubin exceeds 25 mg/dL or if signs of acute bilirubin encephalopathy are present. This newborn’s bilirubin peaked at 18.5 mg/dL and decreased to 14.2 mg/dL with phototherapy, indicating effective response. Thus, exchange transfusion is not currently indicated.

Choice E rationale: Serial bilirubin monitoring is essential to assess treatment efficacy and guide phototherapy duration. The newborn’s bilirubin decreased from 18.5 mg/dL to 14.2 mg/dL, but continued monitoring is needed to ensure sustained improvement and prevent rebound hyperbilirubinemia. Total serum bilirubin levels provide accurate quantification and help determine whether phototherapy can be discontinued or adjusted. This order supports safe, evidence-based management of neonatal jaundice.

Choice A rationale

Transcutaneous electrical nerve stimulation (TENS) operates on the Gate Control Theory of Pain, where non-painful electrical stimuli are applied, attempting to block the transmission of pain signals. The intensity must be manually increased by the client during a contraction to override the escalating pain impulse and achieve maximum analgesic effect when the pain is most intense, providing the best pain modulation.

Choice B rationale

TENS is primarily used for the low back pain and abdominal pain experienced during the active phase of the first stage of labor (cervical dilation), providing a distraction and non-pharmacological pain relief option. It is less effective during the second stage (pushing) and is not typically indicated for the third stage of labor (placental expulsion), which has different pain mechanisms.

Choice C rationale

TENS works by stimulating large sensory nerve fibers to modulate or decrease the perception of pain (pain modulation), offering a sense of control and relief, but it does not eliminate the pain entirely, particularly the intense visceral pain of uterine contractions. It is a non-invasive pain coping mechanism, not an anesthetic agent that would abolish pain sensation.

Choice D rationale

Gestational diabetes mellitus (GDM) is a maternal metabolic condition and is not a contraindication for the use of TENS during labor. The primary contraindications for TENS include the use of a cardiac pacemaker, application over the heart or head, or in the presence of fetal electronic monitoring electrodes that could conduct the current, none of which are related to GDM.