A nurse is contributing to the plan of care for a newborn who has hyperbilirubinemia and requires phototherapy. Which of the following interventions should the nurse include?

Adolescents tend to believe their own actions might have caused their terminal illness. Choice A reason:

This statement reflects a common developmental focus for adolescents, who are often navigating issues related to identity and self-image. While they are aware of their illness, many may prioritize concerns about how they look and how they are perceived by others. This can be a significant aspect of their experience during a terminal illness.

Choice B reason:

Many adolescents imagine death as a type of monster. Although this statement acknowledges a common perception of death among some adolescents, it is not the best choice for reinforcing teaching about the perception of death in the context of a terminal illness. The focus should be on more concrete and realistic aspects of death and its implications.

Choice C reason:

This statement does reflect a valid concern but may not be as prevalent as the concern with appearance in this age group. Many adolescents, especially in a terminal situation, may focus on more immediate concerns, such as how they are perceived.

Choice D reason:

Many adolescents don't understand that death is permanent. While this statement may be true for some adolescents who are still developing a full comprehension of death, it is not the most suitable choice for this scenario. In the context of a terminal illness, it is essential to acknowledge that the adolescent likely has a clear understanding of the finality of death.

Choice D reason: The nurse should report the laboratory result of 2+ proteinuria (Choice D) to the healthcare provider. Proteinuria is the presence of excess protein in the urine, which can indicate a potential kidney problem or a complication related to pregnancy, such as preeclampsia. Preeclampsia is a serious condition characterized by high blood pressure and damage to organs like the liver and kidneys. Therefore, this result needs immediate attention to assess the client's condition properly and take appropriate actions to ensure the safety and well-being of both the mother and the baby.

Choice A reason:

The 2-hour postprandial glucose level of 105 mg/dL (Choice A) is within the normal range. During pregnancy, glucose levels are carefully monitored to check for gestational diabetes. In this case, the result falls within the acceptable range, indicating that the client's glucose levels are stable, and gestational diabetes is not a concern at this time.

Choice B reason:

A negative group B streptococcus (GBS) B-hemolytic result (Choice B) is actually a positive finding. It means that the client does not have an active infection with group B streptococcus, which is essential information for the management of labor and delivery. Therefore, there is no need to report this result to the provider as it indicates a favorable condition.

Choice C reason:

The hemoglobin (Hgb) level of 13 g/dL (Choice C) is within the normal range for a non- pregnant adult female. During pregnancy, blood volume increases, and hemoglobin levels can naturally decrease. However, the provided value is still within the acceptable range, indicating that the client's blood oxygen-carrying capacity is adequate and there is no immediate concern.