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?

The correct answer is choice A, administer a fluid bolus.

Choice A rationale:

Administering a fluid bolus is appropriate when a client’s urine output is low, which in this case is less than the minimum expected output of 30 mL/hr. The dark yellow color of the urine also suggests dehydration or concentrated urine, which can be addressed with increased fluid intake.

Choice B rationale:

Initiating continuous bladder irrigation is typically done to clear the urinary tract of blood clots or debris following urologic surgery, not for low urine output or dark urine. Therefore, this intervention is not indicated based on the given scenario.

Choice C rationale:

Obtaining a urine specimen for culture and sensitivity is an action taken when there is a suspicion of a urinary tract infection. The scenario does not provide evidence of infection, such as fever or cloudy urine with a strong odor, so this would not be the first intervention to anticipate.

Choice D rationale:

Clamping the catheter tubing is done in preparation for catheter removal or to assess if the client can void without the catheter. It is not an appropriate intervention for low urine output or dark urine and could potentially cause bladder distention or discomfort.

This is because the AP’s statement constitutes an intentional tort, which is a wrong that the defendant knew or should have known would be caused by their actions. An assault is defined as intentionally putting another person in reasonable apprehension of an imminent harmful or offensive contact.

The AP’s threat of using restraints and force-feeding the client could cause the client to fear for their safety and dignity, which is an assault.

Choice B. Battery is wrong because battery is defined as intentional causation of harmful or offensive contact with another person without that person’s consent.

The AP did not actually touch the client or carry out the threat, so there was no battery.

Choice C. Negligence is wrong because negligence is an unintentional tort, which occurs when the defendant’s actions or inactions were unreasonably unsafe.

The AP did not act or fail to act in a way that breached the standard of care or caused harm to the client, so there was no negligence.

Choice D. Malpractice is wrong because malpractice is a type of negligence that involves a professional failing to perform their duties according to the standards of their profession.

The AP did not perform any professional duty or service that was below the standard of care or caused harm to the client, so there was no malpractice.