A nurse is assisting in the care of a client who is at 18 weeks of gestation and reports nausea and vomiting daily that lasts throughout the day.
Which of the following findings indicates the client is experiencing a fluid imbalance?

Choice A rationale

Applying warm packs to the perineum is generally discouraged in the immediate postpartum period, especially within the first 24 hours, due to the risk of increasing swelling and discomfort. Cold applications are typically preferred initially to promote vasoconstriction, which helps to reduce edema and numb the area, offering greater pain relief.

Choice B rationale

Routine application of antibiotic ointment to an episiotomy is not standard practice unless there are signs of infection. Episiotomies are clean-contaminated wounds, and prophylactic antibiotic use is generally avoided to prevent the development of antibiotic resistance and disruption of the normal perineal flora. Aseptic wound care is prioritized.

Choice C rationale

Wiping the perineum with toilet tissue after voiding can introduce bacteria from the anal area into the healing episiotomy site, increasing the risk of infection. Perineal care should involve rinsing the area with warm water (e.g., using a peri-bottle) and patting it dry from front to back to minimize bacterial contamination and promote healing.

Choice D rationale

Encouraging the client to take a sitz bath twice per day is beneficial for episiotomy care. The warm water promotes vasodilation, increasing blood flow to the perineal area, which aids in healing and reduces discomfort. It also helps to keep the area clean and can soothe irritated tissues, facilitating recovery.

✅ Anticipated Orders – Rationales

• Initiate morphine per protocol Morphine is commonly used to manage moderate to severe symptoms of NAS. It helps reduce central nervous system irritability and autonomic overactivity by binding to opioid receptors, thereby easing withdrawal symptoms.
• Encourage breastfeeding Breastfeeding is encouraged unless contraindicated (e.g., maternal HIV or ongoing illicit drug use). Breast milk may contain small amounts of opioids if the mother is on medication-assisted treatment (e.g., methadone or buprenorphine), which can help ease withdrawal symptoms in the newborn.
• Offer small, frequent feedings Infants with NAS often have poor feeding due to uncoordinated suck and gastrointestinal symptoms. Small, frequent feedings help maintain adequate nutrition and prevent hypoglycemia.
• Consult social services Given the maternal history of opioid use disorder and lack of stable housing, social services involvement is essential for discharge planning, ensuring a safe environment, and connecting the family with community resources.
• Monitor using the eat, sleep, console scoring tool This tool is a functional assessment method used to evaluate NAS severity and guide treatment. It focuses on the infant’s ability to eat, sleep, and be consoled rather than just symptom counting.

❌ Not Anticipated Order – Rationale

• Administer naloxone Naloxone is contraindicated in neonates with NAS because it can precipitate acute, severe withdrawal. It is only used in cases of life-threatening opioid overdose, not for withdrawal management.