A nurse is assisting with the care of a client who is beginning the third stage of labor.
Which of the following actions should the nurse take first?

Choice A rationale: Skin-to-skin contact, also known as kangaroo care, is scientifically supported to stabilize neonatal autonomic functions such as heart rate, respiratory rate, and temperature. It promotes oxytocin release in both the parent and infant, which reduces stress and enhances bonding. For neonates experiencing neonatal abstinence syndrome (NAS), this contact can reduce irritability and improve feeding behaviors by providing a calming sensory input that mimics the intrauterine environment.

Choice B rationale: Decreasing environmental stimuli such as lighting is a key nonpharmacologic intervention for infants with NAS. Bright lights can exacerbate neurologic excitability, leading to increased irritability, tremors, and poor feeding. Dimming the lights helps reduce sensory overload, allowing the infant’s overstimulated nervous system to settle. This intervention supports autonomic regulation and is consistent with evidence-based care for managing withdrawal symptoms in neonates.

Choice C rationale: Singing to the newborn introduces rhythmic auditory stimulation, which has been shown to soothe infants and promote neurobehavioral organization. In NAS, where infants are hypersensitive to stimuli, soft singing can provide a predictable and calming input that may improve feeding coordination and reduce crying. Auditory bonding also supports maternal-infant attachment, which is critical in the context of maternal substance use and psychosocial stressors.

Choice D rationale: Avoiding a pacifier is contraindicated in NAS care. Non-nutritive sucking via pacifiers is a well-established intervention to soothe irritable neonates and improve feeding coordination. It activates the sucking reflex, which has a calming effect on the central nervous system. Denying this comfort measure may increase distress and worsen symptoms such as tremors and high-pitched crying, making this choice scientifically inappropriate.

Choice E rationale: Swaddling with the legs flexed mimics the fetal position and provides proprioceptive input that helps calm the overstimulated nervous system in NAS. This positioning reduces excessive motor activity and supports neuromuscular control. Flexed swaddling also enhances sleep quality and decreases the frequency of tremors and startle responses, which are hallmark symptoms of opioid withdrawal in neonates.

Choice A rationale

Increased blood pressure is typically not a sign of fluid deficit, but rather can be a compensatory mechanism in early stages or indicate other conditions. In significant fluid imbalance due to nausea and vomiting, hypotension (decreased blood pressure) is more commonly observed as a result of reduced circulating volume.

Choice B rationale

Dry mucous membranes are a reliable indicator of dehydration and fluid volume deficit. When the body loses excessive fluids due to persistent nausea and vomiting, the oral mucosa becomes less hydrated and appears dry or tacky, reflecting reduced interstitial and intracellular fluid.

Choice C rationale

Elastic skin turgor indicates adequate hydration, as the skin quickly returns to its original position when pinched. In a client experiencing a fluid imbalance due to significant vomiting, one would expect to see decreased skin turgor, where the skin remains tented or slowly returns to normal.

Choice D rationale

Decreased heart rate is not a typical finding in fluid volume deficit. Rather, the body compensates for reduced circulating blood volume by increasing the heart rate (tachycardia) to maintain cardiac output and systemic perfusion, ensuring adequate oxygen delivery to tissues.