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?

, dizziness.

Dizziness is a manifestation of hypovolemia, which is a decrease in blood volume due to fluid loss.

Hypovolemia can cause orthostatic hypotension, which is a drop in blood pressure when changing positions. This can lead to dizziness, lightheadedness, or fainting.

Choice A, epistaxis, is wrong because it is not a sign of hypovolemia, but rather a possible cause of it. Epistaxis is a nosebleed that can result from trauma, infection, dryness, or coagulation disorders.

Choice B, headache, is wrong because it is not a specific sign of hypovolemia, but rather a nonspecific symptom that can have many causes. Headache can be associated with dehydration, but it can also be caused by stress, infection, inflammation, or other factors.

Choice D, shortness of breath, is wrong because it is not a sign of hypovolemia, but rather a sign of fluid volume excess.

Fluid volume excess is an increase in blood volume due to fluid retention or overload. Fluid volume excess can cause dyspnea, which is difficulty breathing or shortness of breath.

Normal ranges for blood pressure are 90/60 mm Hg to 120/80 mm Hg for adults.

Normal ranges for heart rate are 60 to 100 beats per minute for adults.

Choice A reason:

Measuring the arm circumference above the insertion site daily is appropriate. When planning care for a client scheduled to receive a peripherally inserted central catheter (PICC) in the arm, it is appropriate for the nurse to include measuring the arm circumference above the insertion site daily. This intervention is essential to monitor for any signs of complications, such as edema or swelling, which could indicate thrombosis or infiltration at the insertion site.

Choice B reason:

Administering sedation Administering sedation is not a routine intervention for a PICC insertion procedure is inappropriate. Sedation might be considered for certain procedures, but it is not typically used for PICC insertions. PICC insertions are generally performed with local anaesthesia at the insertion site.

Choice C reason:

Scheduling an MRI post procedure to verify placement An MRI is not typically used to verify the placement of a PICC. The placement of a PICC is usually confirmed using X-ray or other imaging methods that can visualize the catheter's location within the central veins. Post-procedure verification of PICC placement is essential to ensure proper positioning and to prevent complications.

Choice D reason:

Using gauze to secure an arm board to the involved extremity Using gauze to secure an arm board to the involved extremity is not a common practice for securing a PICC. After a PICC insertion, a securement device specifically designed for PICCs is typically used to secure the catheter in place and prevent movement.