The nurse is caring for a G4P1, 31 weeks and 2 days gestation, 41-year-old patient, with premature prolonged rupture of membranes (PPROM) 7 hours after delivery. Which interventions will the nurse include in the plan of care? Select all that apply.

Choice A reason: Calling the healthcare provider is important, but the immediate priority is to stop the infusion to prevent further fluid overload, which is likely causing the bilateral crackles.

Choice B reason: Providing supplemental oxygen can be necessary if the child is showing signs of respiratory distress, but it is not the primary action to address the underlying issue of fluid overload.

Choice C reason: Stopping the infusion is the most critical action to prevent further fluid overload, which is causing the bilateral crackles. This immediate intervention can help prevent worsening pulmonary enema and respiratory complications.

Choice D reason: Encouraging oral intake is not appropriate in this scenario as the child is already receiving intravenous fluids for severe dehydration. Additionally, with signs of fluid overload, further fluid intake should be carefully managed.

Choice A reason: This statement suggests a rigid schedule for feeding, which may not always align with an infant's natural hunger cues. While some babies may follow a regular feeding pattern, it's essential to prioritize the baby's hunger cues over a strict schedule. Feeding on demand, when the baby shows signs of hunger, is generally recommended to ensure they receive adequate nutrition and comfort.

Choice B reason: Advising not to wake a sleeping baby for feeding is not accurate for all situations. Newborns, especially in the first few weeks, may need to be woken for feeding if they are not gaining weight adequately or if they have medical conditions that require regular feeding. It is important to balance letting the baby sleep and ensuring they get enough nutrition, particularly in the early stages.

Choice C reason: Feeding the baby when they start smacking their lips or sucking on their hands demonstrates an understanding of responding to hunger cues. These behaviours are early signs of hunger, and feeding the baby at this stage can prevent them from becoming overly hungry and fussy. This approach aligns with best practices for feeding on demand, promoting healthy growth and development.

Choice D reason: This statement reflects a misunderstanding of infant care. Crying is a late sign of hunger, and it is important to respond to early hunger cues to prevent distress. The idea that responding too soon to a baby's needs will spoil them is a myth. Timely and responsive care fosters a sense of security and trust in the caregiver-infant relationship, contributing to the baby's overall well-being.