A nurse is caring for a newborn 4 hr after birth. Which of the following actions should the nurse include in the plan of care to prevent jaundice?

A) Ask the client to rate her pain:

Assessing the client's pain is important for overall postpartum care, but it does not directly address the issue of a slightly boggy and displaced fundus. Pain assessment should be done routinely but is not the priority in this situation.

B) Encourage the client to perform Kegel exercises:

Kegel exercises are beneficial for strengthening pelvic floor muscles but do not address the issue of a boggy and displaced fundus. While Kegel exercises can promote postpartum recovery, they are not the priority intervention in this case.

C) Assist the client to the bathroom to void:

This is the correct action. A boggy and displaced fundus may indicate urinary retention, which can contribute to uterine atony. Helping the client to the bathroom to void can relieve bladder distension, allowing the uterus to contract more effectively and reducing the risk of postpartum hemorrhage.

D) Encourage the client to move to the left lateral position:

Moving to the left lateral position can help improve uterine perfusion by relieving pressure on the vena cava, but it does not directly address the issue of urinary retention or a boggy fundus. While changing positions is generally beneficial postpartum, assisting the client to void takes precedence in this situation to address the potential cause of uterine atony.

A) "Postpartum depression is more likely to occur in women who have a history of depression":

This statement demonstrates an understanding of a significant risk factor for postpartum depression. Women with a history of depression are at a higher risk of experiencing postpartum depression due to various factors such as hormonal changes, stressors related to childbirth, and previous episodes of depression.

B) "Postpartum depression usually begins 48 hours after childbirth":

This statement is incorrect. Postpartum depression typically develops within the first few weeks to months after childbirth, rather than within 48 hours. The immediate postpartum period may involve the "baby blues," which are characterized by mood swings and mild depressive symptoms, but postpartum depression is a distinct condition that often develops later.

C) "The most common manifestation of postpartum depression is harming the infant":

This statement is incorrect. While postpartum depression can lead to difficulties in caring for the infant and may affect the mother-infant relationship, the most common manifestations of postpartum depression are feelings of sadness, hopelessness, and worthlessness, along with disturbances in sleep, appetite, and concentration.

D) "It's common for clients who have postpartum depression to exhibit psychotic behavior":

This statement is incorrect. Postpartum psychosis, characterized by severe mental disturbances, hallucinations, and delusions, is a rare but severe complication of childbirth. It is not synonymous with postpartum depression, although they both involve mood disturbances occurring after childbirth. Most women with postpartum depression do not experience psychotic symptoms.