A nurse is assessing a newborn who is 2 hr old. Which of the following findings is an indication of hypoglycemia? (Select all that apply.)

A. Uterine tone soft:A soft uterus can indicate inadequate uterine contraction, which may increase the risk of postpartum hemorrhage. The uterus should be firm and well-contracted after delivery.

B. Blood pressure 136/86 mm Hg:
A blood pressure of 136/86 mm Hg is within the normal range for a postpartum client. While changes in blood pressure should be monitored, this reading alone does not indicate an urgent need for follow-up.

C. Peripheral edema 2+ bilateral lower extremities:
Peripheral edema is a common finding in the postpartum period and is often attributed to fluid shifts and hormonal changes. While it should be monitored, it does not typically require immediate follow-up unless it is severe or associated with other symptoms.

D. Large amount of lochia rubra: While lochia rubra is normal in the first few days postpartum, a large amount could indicate potential bleeding issues or complications if it increases significantly.

E. Pain rating of 3 on a scale of 0 to 10:
A pain rating of 3 on a scale of 0 to 10 is relatively mild and may be expected after a vaginal delivery, especially if the client has undergone an episiotomy. It should be addressed but does not require immediate follow-up unless it worsens or is associated with other concerning symptoms.

F. Breasts soft:
Soft breasts are expected in the early postpartum period, particularly if the client is not breastfeeding or if breastfeeding has not yet been established. However, breastfeeding assessment and support should be provided as part of routine postpartum care.

G. Lateral deviation of the uterus:The uterus should be midline and firm. A lateral deviation could suggest a full bladder or other complications that need to be addressed to prevent further issues such as postpartum hemorrhage.

H. Deep tendon reflexes 1+:
Deep tendon reflexes of 1+ are within the normal range and do not typically require immediate follow-up unless they are absent or hyperactive, which may indicate neurological issues.

A. The client will verbalize appropriate car seat safety.

Teaching about car seat safety is important for the mother's understanding of infant care, but it is not specifically related to the taking-in phase, which primarily focuses on the mother's adjustment and recovery.

B. The client will demonstrate proper bathing of the infant.

Similarly, teaching about infant care, such as proper bathing techniques, is important but may be more appropriate for later phases of postpartum adjustment when the mother is more focused on caring for her infant.

C. The client will identify individual family member roles.

This goal may be more relevant to later phases of postpartum adjustment when the mother begins to integrate the new baby into the family unit. During the taking-in phase, the focus is primarily on the mother's own adjustment.

D. The client will have adequate nutritional intake.

This goal aligns with the priorities of the taking-in phase, which include the mother's physical recovery and well-being. Adequate nutritional intake is essential for postpartum recovery and breastfeeding, making it an appropriate goal for this phase.