A nurse is reviewing the medical record of a client who is requesting an oral contraceptive for birth control.
The nurse should identify which of the following findings as a contraindication for the use of oral contraceptives for this client?

Choice A rationale

Fundal massage is the primary intervention for uterine atony and postpartum hemorrhage to stimulate uterine contraction and tamponade bleeding. However, an amniotic fluid embolism (AFE) is characterized by sudden cardiopulmonary collapse, hypoxia, and coagulopathy, where fundal massage is irrelevant to the underlying pathology.

Choice B rationale

AFE involves the sudden entry of amniotic fluid into the maternal circulation, triggering a massive anaphylactoid reaction, acute respiratory distress, and severe refractory hypotension, leading to cardiac and respiratory arrest. Initiating cardiopulmonary resuscitation (CPR) is often immediately required to support life functions.

Choice C rationale

Assisting the client to empty their bladder may be beneficial during labor to allow the fetal head to descend, but it is not a priority intervention for the life-threatening, acute physiological crisis of an AFE. The immediate focus must be on optimizing oxygenation, circulation, and treating the underlying shock and coagulopathy.

Choice D rationale

AFE causes severe pulmonary vasoconstriction and acute respiratory distress, leading to profound hypoxemia. Applying oxygen at 2 L/min via nasal cannula is insufficient for this level of respiratory compromise; the client requires high-flow oxygen, often nonrebreather mask or mechanical ventilation, to maintain adequate arterial oxygen saturation.

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.