A nurse is assessing a client who is at 38 weeks of gestation.
Upon admission 2 hours ago, the client had irregular contractions, was dilated 2 cm, and was at -1 cm station. Which of the following findings indicates progression in labor?

Choice A rationale:
Swaddling the newborn with flexed extremities decreases hypertonicity and minimizes excessive motor activity caused by central nervous system overstimulation from withdrawal. This therapeutic containment provides proprioceptive comfort, simulating the intrauterine environment and reducing hyperirritability. It helps lower metabolic demand and energy expenditure, promoting better thermoregulation and sleep. Newborns with neonatal abstinence syndrome (NAS) exhibit exaggerated startle and Moro reflexes; tight swaddling minimizes these responses, stabilizing autonomic regulation and preventing unnecessary caloric depletion.

Choice B rationale:
Naloxone is contraindicated in neonates with suspected in-utero opioid exposure because it precipitates acute withdrawal by competitively displacing opioids from mu receptors in the central nervous system. This may cause seizures, severe irritability, hypertension, or respiratory failure due to abrupt reversal of neonatal opioid dependence. Neonatal abstinence syndrome is managed through supportive care and gradual pharmacologic weaning using agents like morphine or methadone, not through opioid antagonism, which disrupts neurochemical homeostasis in the developing brain.

Choice C rationale:
Avoiding eye contact reduces bonding and interferes with parental attachment, which is essential for psychosocial and emotional development. Controlled, gentle eye contact and soothing interactions enhance oxytocin release, helping the newborn modulate stress responses through parasympathetic activation. Infants experiencing withdrawal benefit from secure attachment and gentle caregiver interaction to reduce catecholamine surges. Therefore, parents should be encouraged to provide calm visual and tactile stimulation, not avoidance, which could exacerbate disorganized behavior and emotional dysregulation in the newborn.

Choice D rationale:
The Ballard scoring system is performed once, typically within 12 to 24 hours of life, to assess gestational age based on neuromuscular and physical maturity. Performing this assessment each shift offers no clinical value and increases handling, which can worsen irritability and stress in infants experiencing withdrawal. Frequent unnecessary manipulations elevate norepinephrine levels, causing tremors, tachypnea, and poor feeding coordination, further destabilizing the infant’s autonomic function. Thus, repeated Ballard scoring is clinically inappropriate and potentially harmful.

Choice E rationale:
A low-stimulation environment decreases environmental triggers such as light, noise, and abrupt movement that exacerbate autonomic instability and irritability in neonates with withdrawal. Dimming lights, reducing auditory stimuli, and maintaining a quiet, warm setting minimize sympathetic overactivation. This stabilizes heart rate, promotes restorative sleep, and lowers cortisol and catecholamine release, allowing neurobehavioral recovery. Controlled sensory input reduces metabolic stress, improves feeding coordination, and enhances neurologic organization, which are critical outcomes for infants with neonatal abstinence syndrome.

Choice F rationale:
Daily weight monitoring is crucial to detect nutritional compromise resulting from uncoordinated suck-swallow reflexes, vomiting, or excessive caloric expenditure due to hyperactivity. Infants undergoing withdrawal experience fluctuating metabolic demands and may fail to thrive if intake is inadequate. Monitoring weight ensures early identification of dehydration or malnutrition, guiding caloric adjustments and pharmacologic management. The expected weight loss during the first week is ≤10% of birth weight; persistent or excessive loss requires prompt nutritional and medical intervention.

Choice G rationale:
Breastfeeding is encouraged for mothers who are stable on prescribed methadone or buprenorphine therapy and not actively using illicit substances. Breast milk can decrease withdrawal severity by providing small opioid concentrations that ease neurochemical transition and improve bonding. Contraindication occurs only if the mother uses heroin or other non-prescribed opioids, has HIV infection, or specific contraindicated medications. Abruptly withholding breastfeeding deprives the neonate of immunologic and nutritional benefits, exacerbating irritability and feeding difficulty.

Choice A rationale: A fundal height of 36 cm at 42 weeks gestation is concerning because fundal height should approximate gestational age in weeks ±2 cm. At 42 weeks, expected measurement is about 40–44 cm. A measurement of 36 cm suggests possible intrauterine growth restriction (IUGR) or oligohydramnios, both of which are complications associated with post-term pregnancy. This discrepancy requires further evaluation with ultrasound and fetal surveillance to ensure adequate growth and amniotic fluid volume.

Choice B rationale: A cervix that is closed and thick at 42 weeks gestation is not an immediate problem requiring intervention. Cervical ripening varies, and although induction may be considered at this gestational age, the cervix itself being closed is not pathologic. It simply indicates that spontaneous labor has not yet begun. This finding does not require urgent intervention but may guide decisions about induction methods such as prostaglandins or mechanical ripening.

Choice C rationale: A vertex presentation at +1 station is a favorable finding. Vertex is the optimal presentation for vaginal delivery, and +1 station indicates that the fetal head is descending into the pelvis. This is reassuring and does not require intervention. It suggests that the fetus is well-positioned for labor and delivery, and no abnormality is present in this assessment.

Choice D rationale: Clear to white mucus-like vaginal discharge is a normal physiologic finding in pregnancy, known as leukorrhea. It results from increased estrogen and cervical gland activity. This type of discharge is not associated with infection or rupture of membranes. Since it is expected and benign, it does not require intervention. Only abnormal discharges such as foul-smelling, green, or bloody secretions would warrant further evaluation.

Choice E rationale: A fetal heart rate of 150/min is within the normal baseline range of 110 to 160 beats per minute. This indicates adequate fetal oxygenation and no evidence of tachycardia or bradycardia. Since the rate is normal and reassuring, it does not require intervention. Continuous monitoring remains important, but this specific finding is not problematic.

Choice F rationale: A nonstress test that is nonreactive is concerning because it indicates that the fetus did not demonstrate adequate accelerations of heart rate with movement. A reactive NST requires at least two accelerations of 15 beats/min above baseline lasting 15 seconds within 20 minutes. A nonreactive result suggests possible fetal hypoxemia, sleep state, or neurologic compromise. This requires further evaluation with a contraction stress test or repeat biophysical profile.

Choice G rationale: A positive Group B Streptococcus culture is abnormal and requires intervention. GBS colonization increases the risk of neonatal sepsis, pneumonia, and meningitis if transmitted during delivery. Standard care is intrapartum prophylaxis with IV penicillin or ampicillin during labor. Since this client is GBS positive, the nurse must ensure that prophylactic antibiotics are administered at the onset of labor or rupture of membranes to prevent neonatal infection.

Choice H rationale: A biophysical profile score of 8/10 is considered reassuring. The BPP assesses fetal breathing, movement, tone, amniotic fluid volume, and NST. A score of 8 to 10 indicates normal fetal well-being, while 6 is equivocal and ≤4 is abnormal. Since this client’s score is 8, no immediate intervention is required. This is a reassuring finding and does not indicate fetal compromise.