An antenatal client at 32 weeks' gestation has been admitted to the hospital with premature rupture of membranes.
She is not exhibiting any signs of labor.
What is the priority nursing intervention for this client?

Choice A rationale

Administering oral glucose for comfort can provide analgesia and soothe a newborn experiencing withdrawal symptoms, which often include irritability and crying. The hyperglycemic solution activates sweet taste receptors and provides a calming effect. It does not alter the newborn's withdrawal process but aids in temporary relief from discomfort caused by neonatal abstinence syndrome. Sweet solutions are commonly used for procedural pain management in neonates.

Choice B rationale

Observing the newborn in a well-lit nursery is inappropriate for managing withdrawal symptoms. Bright lights can overstimulate the newborn and exacerbate symptoms such as irritability and crying. Neonates exposed to heroin in utero often require a low-stimulation environment to prevent sensory overload, as their central nervous system is already compromised by drug exposure. Excessive stimulation can worsen withdrawal effects, increasing stress for the infant.

Choice C rationale

Maintaining a low-stimulation environment is critical for newborns experiencing withdrawal. These infants benefit from dim lighting, minimal noise, and reduced handling, as their central nervous system is hypersensitive. High stimulation may intensify symptoms like tremors and irritability. A controlled, soothing environment helps stabilize the newborn's condition by promoting better neurological regulation and decreasing withdrawal-related distress.

Choice D rationale

Offering the newborn a pacifier helps to satisfy non-nutritive sucking needs, which are often heightened in neonates with withdrawal symptoms. The act of sucking can comfort the infant and reduce irritability associated with neonatal abstinence syndrome. Non-nutritive sucking is a self-soothing behavior that has been proven to decrease stress responses and stabilize physiological parameters in affected infants.

Choice E rationale

Feeding the infant half-strength formula is inappropriate as it can lead to nutritional deficiencies, which are harmful to a newborn already at risk due to prenatal drug exposure. Newborns require adequate caloric intake to support growth and recovery. Half-strength formula lacks sufficient nutrients necessary for healthy weight gain and organ development. Full-strength, nutrient-rich feeding is advised for optimal neonatal care.

Choice F rationale

Swaddling the newborn with legs flexed mimics the intrauterine environment and provides a sense of security to a neonate undergoing withdrawal symptoms. This method reduces sensory stimulation and decreases distress, helping stabilize the infant's condition. Swaddling promotes calming and decreases excessive movements such as tremors, which are characteristic of neonatal abstinence syndrome. It is a widely accepted comfort measure.

Choice A rationale

Maximizing skin exposure to phototherapy lights ensures effective breakdown of bilirubin through photoisomerization, reducing serum bilirubin levels. Phototherapy converts unconjugated bilirubin to water-soluble isomers that are excreted via bile and urine. Exposing more skin enhances light absorption, increasing treatment efficacy. Normal bilirubin levels in newborns range from 1 to 12 mg/dL. This intervention aligns with standard protocols for managing hyperbilirubinemia in neonates.

Choice B rationale

Applying lotion during phototherapy can cause skin burns by altering light penetration and causing a thermal effect. It may also increase the risk of skin irritation and infections. Phototherapy lights generate heat, and lotions can exacerbate these effects, leading to complications. Effective bilirubin management depends on clean, dry skin under the lights.

Choice C rationale

While eye shields are critical to protecting the infant’s retina and cornea from potential phototoxicity, removing them during breastfeeding is necessary. This promotes bonding and facilitates feeding. Continuous shield use can obstruct parental interaction and feeding, which are vital for infant care. Shielding should only occur during phototherapy exposure.

Choice D rationale

Swaddling restricts skin exposure to the therapeutic lights, negating the benefits of phototherapy. It prevents effective breakdown of bilirubin as less skin is exposed to the treatment. Neonates under phototherapy should be minimally clothed, often only wearing a diaper, to maximize light absorption and ensure treatment success.