A nurse is admitting a client who is at 35 weeks of gestation and is experiencing mild vaginal bleeding due to placenta previa. Which of the following actions should the nurse plan to take?

Choice A rationale:

Checking the newborn's temperature every 8 hours is not directly related to managing hyperbilirubinemia or phototherapy. Monitoring the newborn's temperature is important, but it should be done more frequently, especially during phototherapy, as infants are at risk of developing hypothermia.

Choice B rationale:

Applying moisturizing lotion to the newborn's skin every 4 hours is not a necessary intervention for hyperbilirubinemia or phototherapy. While skin care is important for all newborns, it is not a specific intervention for this condition.

Choice C rationale:

Giving the newborn 1 oz of glucose water every 4 hours is not an appropriate intervention for hyperbilirubinemia. Glucose water is not a recommended treatment for this condition.

Instead, phototherapy helps break down the bilirubin and promote its elimination from the body.

Choice D rationale:

Repositioning the newborn every 2 to 3 hours is the correct intervention. Repositioning helps ensure even exposure of the baby's skin to the phototherapy lights, maximizing its effectiveness in reducing bilirubin levels. Additionally, repositioning prevents pressure ulcers and promotes comfort for the infant during treatment.

The correct answers are C, D, E.

Choice A reason:

Performing a vaginal exam is contraindicated in placenta previa because it can disrupt the placenta and cause significant bleeding.

Choice B reason:

Monitoring fetal heart rate with an internal fetal monitor is not recommended as it involves a vaginal exam, which poses a risk of bleeding in placenta previa cases.

Choice C reason:

Frequently assessing maternal heart rate is important to detect any changes that could indicate maternal hemorrhage or other complications.

Choice D reason:

Initiating bed rest with bathroom privileges is advised to minimize the risk of bleeding and to ensure the safety of both the mother and the fetus.

Choice E reason:

Having oxygen equipment available is essential to manage potential fetal distress, which can occur with placenta previa.