A nurse is reinforcing teaching about travel with a client who is pregnant.
Which of the following instructions should the nurse include?

Choice A rationale

Providing additional hydration by offering glucose water is not recommended. Breast milk or formula should be the primary source of hydration for newborns.

Choice B rationale

Monitoring the newborn’s heart rate every 2 hours is not necessary for phototherapy. The focus should be on monitoring bilirubin levels, hydration status, and ensuring the newborn’s eyes are protected.

Choice C rationale

Applying a water-based lotion to the newborn’s skin every 4 hours is not recommended. Lotions can interfere with the effectiveness of phototherapy and may cause skin irritation.

Choice D rationale

Removing the newborn from phototherapy every 2 hours for breastfeeding is recommended. Frequent breastfeeding helps to promote bilirubin excretion and maintain hydration.

Choice A rationale

Deep tendon reflexes of 1+ are considered within normal limits and do not require immediate follow-up. This finding is not indicative of any acute complications.

Choice B rationale

A blood pressure reading of 136/86 mm Hg is slightly elevated but not critically high. It does not indicate an immediate risk and can be monitored with routine care.

Choice C rationale

A pain rating of 3 on a scale of 0 to 10 is mild and manageable. It does not necessitate immediate follow-up unless there is a sudden and significant increase in pain.

Choice D rationale

A large amount of lochia rubra can be a sign of excessive bleeding and requires immediate follow-up to assess for postpartum hemorrhage. This finding is concerning and needs prompt attention.

Choice E rationale

Peripheral edema of 2+ in bilateral lower extremities is common in the postpartum period due to fluid shifts and should resolve naturally. It does not require immediate follow-up unless it worsens or is accompanied by other symptoms.

Choice F rationale

Soft breasts are normal postpartum when milk has not yet come in or if the client is not breastfeeding. This finding does not require immediate follow-up as it is a normal occurrence.

Choice G rationale

A soft uterine tone can indicate uterine atony, which can lead to hemorrhage. Immediate follow-up is necessary to prevent potential complications such as postpartum hemorrhage.

Choice H rationale

Lateral deviation of the uterus can indicate a displaced uterus, possibly due to a full bladder or other reasons, which requires prompt attention. This finding could lead to complications if not addressed promptly. .