A nurse is developing a plan of care for a newborn whose mother tested positive for heroin during pregnancy.

The newborn is experiencing neonatal abstinence syndrome.

Which of the following actions should the nurse include in the plan?

This is a sign of preeclampsia, a serious complication of pregnancy that can cause high blood pressure, proteinuria, and seizures.

Preeclampsia can affect the placenta, the kidneys, the liver, and the brain of the mother and the fetus. It requires immediate medical attention and may lead to early delivery.

Choice A, bleeding gums, is wrong because it is a common occurrence during pregnancy due to hormonal changes that increase blood flow to the gums. It is not a cause for concern unless it is excessive or accompanied by other symptoms.

Choice B, urinary frequency, is wrong because it is also a normal finding during pregnancy due to the growing uterus putting pressure on the bladder. It is not a sign of infection or kidney problems unless it is associated with pain, burning, or blood in the urine.

Choice D, faintness upon rising, is wrong because it is usually caused by orthostatic hypotension, a drop in blood pressure when changing positions.

This can happen during pregnancy due to the dilation of blood vessels and the increased blood volume. It can be prevented by rising slowly, drinking enough fluids, and avoiding prolonged standing.

The correct answer is Choice A.

Choice A rationale:

• Acknowledges the client's feelings:It's important for the nurse to validate the client's concerns and let them know that it's understandable to feel nervous or uncertain about ECT.
• Provides information about the treatment:The nurse can offer information about the potential benefits of ECT,but it's important not to pressure the client or make them feel like they have to go through with it.
• Reassures the client of their right to change their mind:This is a crucial aspect of informed consent.The client has the right to withdraw their consent at any time,even after signing the consent form.

Choice B rationale:

• Places undue pressure on the client:This response implies that the doctor knows what's best for the client and that the client should go through with the treatment even if they have doubts.This can undermine the client's autonomy and decision-making ability.

Choice C rationale:

• May minimize the client's concerns:While rescheduling the treatment is an option,it's important to explore the client's concerns more thoroughly before suggesting this.It's possible that the client has valid reasons for not wanting to go through with ECT,and these reasons should be addressed.

Choice D rationale:

• Is disrespectful of the client's autonomy:This response suggests that the client is obligated to go through with the treatment simply because they signed a consent form.This ignores the fact that people can change their minds and that consent is an ongoing process.