A nurse is planning care for a client who is 2 weeks postpartum and has mastitis. Which of the following interventions should the nurse include? (Select all that apply.)

Choice A reason:

"Retract the foreskin until you feel resistance." This advice is not recommended for newborns with an uncircumcised penis. The foreskin of most male babies doesn't yet pull back (retract) fully at birth, and forcing it back can cause pain, bleeding, and possible damage.

Choice B reason:

"Use a cotton swab to clean under the foreskin." This is not advisable for a newborn's uncircumcised penis. The foreskin is usually still attached to the glans and does not require any special cleaning inside. Using a cotton swab could potentially cause harm by forcing the foreskin back.

Choice C reason:

"Apply petroleum jelly to the foreskin." This instruction is more applicable to a circumcised penis during the healing process to prevent the penis from sticking to the diaper. For an uncircumcised penis, there's no need to apply petroleum jelly as part of regular care.

Choice D reason:

"Wash the penis once per day with soap and water." This is the correct care for an uncircumcised penis. Parents should gently wash the genital area with mild soap and water during bath time without retracting the foreskin.

Choice A rationale:

The priority nursing action when the fetal heart rate shows a deceleration after the contraction has started, with the lowest point occurring after the peak of the contraction, is to change the client's position. This deceleration pattern is called "late decelerations,” and it is typically associated with uteroplacental insufficiency, which can be caused by maternal hypotension or impaired blood flow to the placenta. Changing the client's position, such as moving the client to their side or repositioning them, can alleviate pressure on the vena cava and improve blood flow to the placenta, thus potentially resolving or minimizing the late decelerations.

Choice B rationale:

Inserting a scalp electrode (Choice B) is not the priority action in this situation. While a scalp electrode may be used to monitor the fetal heart rate more accurately and continuously, it is not the initial intervention for addressing late decelerations.

Choice C rationale:

Preparing for amnioinfusion (Choice C) may be considered if there are variable decelerations (caused by cord compression) present, but it is not the priority intervention for late decelerations.

Choice D rationale:

Documenting benign decelerations (Choice D) is not appropriate in this scenario since late decelerations are not considered benign and require immediate action.