The preliminary management of a 6-year-old diagnosed with nocturnal enuresis (bedwetting) focused on behavioral modifications and positive reinforcement. Follow-up evaluation determines no significant improvement. The nurse practitioner should change the plan to include:

Rationale: A. Bowel cleansing may be considered if constipation is contributing, but it is not the standard next step when behavioral strategies alone fail. B. Urinalysis is useful for ruling out underlying urinary tract infections or diabetes but is typically performed earlier in the evaluation process. C. A bedwetting alarm is a first-line second-step intervention after behavioral modifications have not produced improvement. It conditions the child to wake in response to bladder fullness and has demonstrated efficacy in reducing nocturnal enuresis. D. Referral to a pediatric urologist is generally reserved for refractory cases, underlying anatomic abnormalities, or complicated presentations, not as the immediate next step after failed behavioral therapy.