A nurse is caring for a newborn whose mother was taking methadone during her pregnancy.

Which of the following findings indicates the newborn is experiencing withdrawal?

A: Review the need for the indwelling urinary catheter daily.
This is correct because indwelling catheters should be removed as soon as possible to reduce the risk of urinary tract infection (UTI).

B: Place the drainage bag on the bed when transporting the client.
This is incorrect because the drainage bag should be kept below the level of the bladder and should not touch the floor to prevent the backflow of urine and contamination of the catheter.

C: Use soap and water to provide perineal care.
This is correct because soap and water can help to remove bacteria and debris from the meatus and prevent infection.

D: Encourage the client to drink 3000 mL of fluid daily.
This is incorrect because the client has a fluid restriction of 1000 mL daily due to heart failure. Excessive fluid intake can worsen the client’s condition and increase the workload of the heart.

E: Change the indwelling urinary catheter tubing every 3 days.
This is incorrect because changing the catheter tubing can increase the risk of infection by breaking the closed drainage system. The catheter tubing should only be changed when it is visibly soiled or malfunctioning.

F: Empty the drainage bag when it is half full.
This is incorrect because the drainage bag should be emptied at least every 8 hours or when it is one-third full to prevent back pressure and infection.

The correct answer is choice D. The nurse should include that information technology will install a firewall to secure client information.

A firewall is a system that protects the network from unauthorized access and prevents data breaches. A firewall is essential for ensuring the confidentiality, integrity, and availability of electronic health records .

Choice A is wrong because the nurse should change their password more frequently than once per year. Changing passwords regularly reduces the risk of unauthorized access and enhances security .

Choice B is wrong because the documentation of sensitive material is not performed by the charge nurse. The nurse who provides the care should document it accurately and promptly in the computerized system .

Choice C is wrong because the nurse will not be given access to the medical records of every client in the facility. The nurse should only access the records of the clients they are assigned to care for, following the principle of need-to-know .