A nurse is caring for a 2-day-old newborn who has a bilirubin level of 14 mg/dL (1 to 12 mg/dL) and is to begin phototherapy.
Which of the following actions should the nurse take?

Choice A rationale

An indwelling urinary catheter can increase the risk of falls because it may cause discomfort and restricted mobility, leading the client to move awkwardly or lose balance.

Choice B rationale

While a second-degree perineal laceration might cause pain and limited mobility, it doesn't usually contribute as significantly to fall risk as an indwelling catheter.

Choice C rationale

Saturating a perineal pad every 5 to 6 hours may indicate heavy postpartum bleeding, but it isn't directly related to fall risk. The concern here would be more about monitoring for hemorrhage rather than falls.

Choice D rationale

Breast engorgement causes discomfort and pain but doesn't directly affect a client's mobility or balance, making it less likely to increase fall risk.

Choice A rationale

Music can be a non-pharmacological method to help manage pain and anxiety during the latent phase of labor.

Choice B rationale

Biofeedback might be helpful but can be challenging to implement without prior training.

Choice C rationale

Administering fentanyl 100 mg every hour is not appropriate; fentanyl is typically administered in much smaller doses.

Choice D rationale

A pudendal nerve block is usually reserved for the second stage of labor or delivery, not the latent phase.