A nurse is caring for a newborn who is 5 days old in the newborn nursery unit.

Exhibits

Which of the following actions should the nurse take? Select all that apply.

Vaginal bleeding

Bleeding occurs in placenta previa due to partial or total implantation of the placenta over the cervical os, leading to painless bright red bleeding from disrupted placental vessels. It also occurs in preterm labor when cervical effacement and dilation disrupt small cervical vessels, producing light bleeding or spotting. In abruptio placenta, bleeding is dark red and may be concealed or apparent, resulting from premature placental detachment and rupture of maternal vessels in the decidua basalis.

Uterine contractions

Regular uterine contractions every 2 to 3 minutes with cervical change are diagnostic of preterm labor, resulting from premature activation of uterine oxytocin receptors and prostaglandin release before 37 weeks. In abruptio placenta, contractions are often strong and sustained (hypertonic uterus) due to myometrial irritability from bleeding into the decidual layer. Placenta previa, however, typically presents with painless bleeding and a soft, relaxed uterus without contractions because the uterine muscle tone remains unaffected.

Cervical dilation

Cervical dilation indicates preterm labor, as biochemical changes in the cervix from increased prostaglandin and relaxin activity cause collagen breakdown and effacement before term. This process reflects uterine activation sequence initiation leading to potential preterm birth. In placenta previa, the cervix may remain closed despite bleeding because bleeding originates from placental implantation, not cervical change. Abruptio placenta rarely involves dilation unless labor progresses secondarily after placental separation, thus cervical dilation is not a key feature.

Abdominal tenderness

Abdominal tenderness is characteristic of abruptio placenta, caused by bleeding between the uterine wall and placenta leading to myometrial irritability, uterine rigidity, and ischemic pain. The trapped blood increases intrauterine pressure, stimulating pain receptors in the myometrium and stretching the uterine serosa. Placenta previa presents with a soft, nontender abdomen because bleeding is external and not associated with uterine muscle involvement. Preterm labor generally causes back discomfort or cramping, not localized abdominal tenderness.

Client report of low back pain

Low back pain is prominent in preterm labor, resulting from referred pain due to rhythmic uterine contractions transmitted through the lumbosacral plexus and pelvic nerves. It reflects early cervical change and uterine irritability. In abruptio placenta, the back pain may occur secondary to uteroplacental separation and posterior placental bleeding irritating the parietal peritoneum. Placenta previa typically lacks pain or back discomfort since bleeding occurs without uterine or peritoneal irritation.

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.