A nurse is caring for a newborn who has herpes simplex virus as a result of in utero transmission.
Which of the following actions should the nurse take?

Choice A rationale

Bladder distention upon palpation indicates urinary retention, not effective voiding. When the bladder remains distended, it signifies incomplete emptying, which can lead to urinary stasis and increased risk of urinary tract infections. Effective voiding requires coordinated detrusor muscle contraction and urethral sphincter relaxation, which is absent with distention.

Choice B rationale

A uterine fundus 2 cm above the umbilicus, especially in the postpartum period, suggests uterine atony and possible bladder distention. A full bladder can displace the uterus upward and to the side, preventing effective uterine contraction and involution, which is crucial for preventing postpartum hemorrhage. Normal fundal height should decrease daily.

Choice C rationale

Not feeling the urge to urinate could indicate nerve damage, overdistention with sensory nerve suppression, or a very low urine output. Normal bladder sensation is crucial for effective voiding. The absence of the urge may lead to prolonged bladder distention, increasing the risk of infection and bladder dysfunction, which hinders efficient emptying.

Choice D rationale

Urinating 30 mL/hr, while seemingly low, is a continuous output and suggests the client is able to empty their bladder, albeit slowly. Postpartum diuresis typically begins within 12 hours, with urine output of 100 to 250 mL/hr common. However, any consistent output, rather than retention, indicates some voiding effectiveness.

Choice A rationale

Bilirubin levels are typically monitored by a healthcare professional and not by parents at home every 6 hours. The frequency of bilirubin checks for a newborn receiving home phototherapy is usually determined by the healthcare provider based on the infant's bilirubin trajectory and clinical status, often daily or as prescribed.

Choice B rationale

Offering glucose water to newborns is not recommended. Glucose water does not provide adequate nutrition and can interfere with successful breastfeeding or formula feeding by reducing the infant's appetite for nutrient-rich milk. Adequate hydration and nutrition are crucial for bilirubin excretion in jaundiced infants.

Choice C rationale

For biliblanket phototherapy, eye coverings are generally not necessary. The biliblanket emits light from a fiber optic pad that is wrapped around the infant's body, and the light does not directly shine into the baby's eyes, unlike traditional overhead phototherapy lights that require eye protection.

Choice D rationale

Removing the baby from the biliblanket for feedings is appropriate and encouraged. Intermittent breaks for feeding and bonding are permissible as long as the total duration of phototherapy prescribed by the healthcare provider is met. Frequent feedings promote bilirubin excretion through stools.