A nurse is assessing a newborn who has neonatal abstinence syndrome. Which of the following findings should the nurse expect?

A. To facilitate bonding between the newborn and parent. This is correct. Antibiotic ophthalmic ointment, typically used to prevent neonatal conjunctivitis, can temporarily blur the newborn's vision. Delaying its application for a short period allows the newborn to maintain eye contact with the parent during the critical bonding period immediately following birth.

B. To allow manifestations of infection to be identified. This is incorrect. The purpose of the antibiotic ointment is to prevent neonatal conjunctivitis caused by gonorrhea or chlamydia, which may not present with immediate symptoms. Delaying its application to observe for signs of infection would not be appropriate.

C. The newborn's weight is not a determining factor for delaying the instillation of antibiotic ophthalmic ointment.

D. The mode of delivery, whether vaginal or cesarean, does not affect the timing of antibiotic ophthalmic ointment instillation.

Rationale:

A. Inserting a urinary catheter is an invasive procedure and should not be the first action taken to address bladder distention following a vaginal birth. It should only be considered if the client is unable to void voluntarily.

B. Assisting the client to the bathroom is the initial intervention to attempt to relieve bladder distention. Encouraging the client to void in a comfortable and familiar environment may stimulate urination and help alleviate the distention.

C. Offering the client a sitz bath may provide comfort and promote perineal healing but is not the first intervention for bladder distention.

D. Pouring warm water over the client's perineum may also provide comfort but does not directly address bladder distention.