A nurse is caring for a newborn who is experiencing neonatal abstinence syndrome. Which of the following actions should the nurse take?

A. "You can add honey to sweeten vegetables if they do not like them." Honey should be avoided in infants under 12 months due to the risk of infant botulism, a serious and potentially fatal illness caused by Clostridium botulinum spores.
B. "Raw carrots are a good snack to provide and can help with teething." Raw carrots pose a choking hazard for infants and should not be given in solid form. Teething rings or soft, age-appropriate snacks are safer alternatives for teething relief.
C. "You can mash canned vegetables instead of purchasing baby food." Canned vegetables often contain added sodium, which is not recommended for infants. Fresh or frozen vegetables without added salt are a safer option when preparing homemade baby food.
D. "Introduce one new food every 3 to 5 days when starting solid foods." This approach allows the caregiver to monitor for allergic reactions or food sensitivities. Introducing foods gradually helps identify the cause of any adverse response and promotes safe dietary progression.

A. Heart rate. The client has a heart rate of 120/min, which is tachycardia and may indicate dehydration, mania-related hyperactivity, or a response to poor nutritional status. This requires immediate follow-up to assess for cardiovascular strain or fluid imbalance.
B.Sleep deprivation (has not slept for 2 days) can exacerbate mania, contribute to delirium, and impair judgment. This requires prompt intervention to ensure safety and stabilization.

C. Hallucinations. The client is responding to internal stimuli, indicating active psychosis, which poses a safety risk to the client and others. Hallucinations require immediate intervention to stabilize mental health and prevent harm.
D. Skin turgor. Poor skin turgor suggests dehydration, which is a priority physiological concern, especially when paired with tachycardia and failure to recall last food intake. This finding indicates the need for fluid and electrolyte evaluation and possible replacement.
E. Poor hygiene is important for overall care but is not an immediate threat to the client’s safety or physiological stability. It can be addressed after urgent medical and psychiatric concerns are managed.