A nurse is caring for a patient who is receiving oxytocin via continuous IV infusion and is experiencing persistent late decelerations in the FHR.
After discontinuing the infusion, what action should the nurse take?

Choice A rationale: Swaddling the newborn with flexed extremities can provide a sense of security and help soothe the newborn. This is a common practice in managing neonates with Neonatal Abstinence Syndrome (NAS) as it can help reduce irritability and promote sleep.

Choice B rationale: Naloxone is not typically used in the treatment of NAS. Naloxone is an opioid antagonist and can precipitate withdrawal symptoms in opioid-dependent individuals. In a neonate with NAS due to maternal opioid use, naloxone can cause severe and immediate withdrawal.

Choice C rationale: Maintaining a low stimulation environment is crucial in managing neonates with NAS. These neonates are often hypersensitive to stimuli, and a quiet, dimly lit environment can help reduce irritability and promote sleep.

Choice D rationale: Breastfeeding is usually encouraged in mothers who are stable on their opioid replacement therapy, are not using illicit drugs, and have no other contraindications for breastfeeding. The benefits of breastfeeding include the passage of maternal antibodies and the promotion of mother-infant bonding.

Choice E rationale: The Ballard newborn screening is a tool used to estimate gestational age using physical and neuromuscular characteristics. It is typically performed shortly after birth and may not need to be performed each shift in a neonate with NAS.

Choice F rationale: Weighing the newborn daily is important in the management of NAS. Weight can provide information about feeding and hydration status, and any significant or sudden changes in weight can indicate a need for further evaluation.

Choice G rationale: Eye contact during feeding can promote bonding between the parent and the newborn. There is no need to avoid eye contact during feeding in a neonate with NAS.

Choice A rationale
A hematocrit level of 37% is within the normal range for a pregnant woman, which is 33% to 46%. Therefore, this result does not need to be reported to the provider.
Choice B rationale
A fasting blood glucose level of 180 mg/dL is significantly higher than the normal range of 74 to 106 mg/dL. This could indicate gestational diabetes, which can lead to various complications for both the mother and the baby. Therefore, this finding should be reported to the provider.
Choice C rationale
A creatinine level of 0.9 mg/dL is within the normal range of 0.5 to 1 mg/dL for a female client aged 18 to 40 years.
Choice D rationale
A WBC count of 11,000/mm is slightly above the normal range of 5,000 to 10,000/mm. However, it’s common for the WBC count to increase during pregnancy due to physiological changes. Therefore, this result does not need to be reported to the provider.