A nurse is caring for a newborn who is 72 hr old.

Vital signs

0900:

• Heart rate 160/min
• Respiratory rate 80/min
• Temperature 38.1° C (100.6° F)
• Oxygen saturation 97%

1000:

• Heart rate 167/min
• Respiratory rate 72/min
• Temperature 38°C (100.4°F)
• Oxygen saturation 97%

Medical History

0900:

A term newborn 37 weeks of gestation is admitted to the newborn nursery following a precipitous vaginal birth. Birthing parent has a history of heroin use during pregnancy and prenatal care beginning at 34 weeks of gestation. Birthing parent and newborn drug screens positive for heroin.

The nurse is planning to contact the provider regarding the newborn's status. Which of the following prescriptions should the nurse anticipate? Select the 3 interventions the nurse should anticipate.

Rationale:

A. This statement is overly dismissive and does not provide the client with accurate information about herbal therapies. Herbal therapies can have benefits for some individuals, but their efficacy and safety can vary widely.

B. "Many herbal products have not undergone long-term testing for safety and efficacy." This statement provides important information to the client about the potential risks associated with herbal therapies. It emphasizes the need for caution and informed decision-making when considering their use.

C. This statement is premature and does not address the need for further assessment or consideration of potential risks and benefits before starting herbal therapies.

D. This statement is inaccurate, as herbal therapies can have side effects and interactions with medications. It does not adequately inform the client about the potential risks associated with herbal therapies.

A. This choice is partially correct because it addresses the parent's concern by offering to

involve the supervisor. However, it does not provide the parent with the specific reason why the incident was reported.
B. This response defers the explanation to another time and person, which may increase the parent's frustration or anxiety.
C. This choice explains the action taken but does not clarify the nurse's legal obligation to report the incident, which is the central issue.
D. This is the most appropriate response as it clearly communicates the nurse's legal responsibility to report any suspected cases of child abuse, providing transparency and understanding of the actions taken.