A nurse is caring for a newborn who is 5 days old.
Medical History

History of maternal opioid use prior to pregnancy and prescribed methadone use during pregnancy. Maternal and neonatal positive urine drug screens for methadone. Newborn is exhibiting clinical findings of neonatal abstinence syndrome (NAS).


Which of the following actions should the nurse take? Select all that apply.

Platelet count 90,000/mm3: Sign of Potential Worsening Condition - A decreased platelet count may indicate worsening preeclampsia and a risk of developing HELLP syndrome or thrombocytopenia.

Hematuria: Sign of Potential Worsening Condition - Hematuria suggests potential kidney involvement, which is a serious complication of preeclampsia, indicating a worsening condition. Positive clonus: Sign of Potential Worsening Condition - Positive clonus is a neurological sign associated with preeclampsia and indicates hyperreflexia, which can lead to seizures if untreated. Proteinuria 2+: Sign of Potential Worsening Condition - Increased proteinuria indicates ongoing kidney dysfunction, which is a worsening sign of preeclampsia.

Leukorrhea: Sign of Potential Improvement - Leukorrhea, an increase in vaginal discharge, may indicate a reduction in cervical mucus plug, which is a normal finding in late pregnancy.

BUN 40 mg/dL: Sign of Potential Worsening Condition - Elevated blood urea nitrogen (BUN) levels indicate impaired kidney function, which is a worsening sign of preeclampsia and can lead to complications such as acute kidney injury.

Rationale:

A. Tubal ligation does not typically affect the length of menstrual periods.

B. While tubal ligation may prevent pregnancy, it does not directly impact premenstrual tension.

C. Hormone replacement therapy is not typically indicated following tubal ligation unless there are other underlying medical reasons for hormone imbalance.

D. "Ovulation will remain the same" is correct. Tubal ligation prevents pregnancy by blocking the fallopian tubes, but it does not affect ovulation. Therefore, the client will continue to ovulate normally after the procedure.