A nurse is planning care for a 4-hour-old newborn born to a client who has a prenatal history of substance use disorder. Which of the following interventions should the nurse include in the plan of care?

Choice A rationale:

Chronic hypertension significantly increases the risk of complications such as preeclampsia, intrauterine growth restriction, and placental abruption. Normal blood pressure is <120/80 mmHg. Elevated blood pressure can damage blood vessels and organs, affecting placental function.

Choice B rationale:

A sedentary lifestyle can lead to excessive weight gain, gestational diabetes, and venous thromboembolism. Lack of physical activity is linked to poor cardiovascular health and increased risk of preeclampsia. Regular exercise is recommended to mitigate these risks.

Choice C rationale:

Occasional dizziness is common during pregnancy due to hormonal changes, increased blood volume, or postural hypotension. It is not a major risk factor for pregnancy complications unless associated with other symptoms like severe headache or visual disturbances.

Choice D rationale:

Consuming 1 cup of coffee daily (approximately 95 mg of caffeine) is generally considered safe during pregnancy. The American College of Obstetricians and Gynecologists states that moderate caffeine intake (<200 mg/day) does not significantly increase the risk of pregnancy complications.

Choice A rationale

Fever, tachycardia, abdominal pain, and purulent discharge are classic signs of endometritis, which is a postpartum infection of the uterine lining, indicating an inflammatory response to bacterial invasion.

Choice B rationale

Hypertension, headache, blurry vision, and chest pain are symptoms more indicative of preeclampsia or hypertensive disorders, not endometritis, which primarily affects the reproductive system.

Choice C rationale

Hyperglycemia, dehydration, and frequent urination are indicative of diabetes mellitus, particularly in cases of diabetic ketoacidosis, not associated with postpartum uterine infections.

Choice D rationale

Hypothermia, bradycardia, and jaundice suggest liver dysfunction or severe infections leading to sepsis, but these are not primary manifestations of endometritis which involves local uterine infection.