A new mother received epidural anesthesia during labor and had a forceps delivery after pushing for 2 hours.At 6 hours post-partum, the client is anxious and restless.
On further assessment, a large perineal hematoma is seen.
She is unable to urinate.
After notifying the physician, the nurse should plan to:

Choice A rationale: Initiating phototherapy is essential for treating neonatal jaundice. Phototherapy helps to break down bilirubin in the skin, reducing serum bilirubin levels and preventing complications such as kernicterus. It is a common and effective treatment for elevated bilirubin levels in newborns.

Choice B rationale: Administering intravenous dextrose addresses the newborn's low blood glucose level. Hypoglycemia in newborns can lead to severe neurological complications if not treated promptly. Dextrose administration helps stabilize blood glucose levels, improving the newborn's overall condition.

Choice C rationale: Performing a lumbar puncture is not indicated in this scenario. The newborn's symptoms and diagnostic results do not suggest a need for this procedure. Lumbar punctures are typically performed to diagnose conditions such as meningitis, which is not evident here.

Choice D rationale: Encouraging frequent breastfeeding or formula feeding helps in reducing bilirubin levels and maintaining blood glucose levels. Adequate feeding promotes regular bowel movements, aiding in the excretion of bilirubin, and ensures the newborn receives necessary nutrients to stabilize blood glucose levels.

Choice E rationale: Administering naloxone is used for opioid withdrawal, which is not relevant in this case. The newborn's symptoms do not indicate opioid exposure, so this intervention is unnecessary.

Choice A rationale

Asking if the client has considered harming her newborn is a priority to assess for potential postpartum depression or psychosis, which require immediate intervention. .