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. 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.

A. The client cleans the perineum with a squeeze bottle after urinating:

This action is a recommended postpartum hygiene practice. Using a squeeze bottle filled with warm water to gently clean the perineum after urinating helps to promote cleanliness and prevent infection. It is important to maintain good hygiene in the perineal area to support wound healing and reduce the risk of complications.

B. The client's perineal suture line is well-approximated:

A well-approximated perineal suture line indicates that the edges of the laceration have been properly aligned and closed with sutures. This is an essential aspect of wound management, as it promotes healing by primary intention. When the wound edges are closely aligned and secured, it reduces the risk of infection and supports optimal healing.

C. The client is changing the perineal pad once daily:

Changing the perineal pad only once daily is a suboptimal practice that can contribute to delayed wound healing. Postpartum clients with perineal lacerations should change their perineal pads frequently, at least every 4 to 6 hours, to maintain cleanliness and prevent excessive moisture buildup, which can increase the risk of infection and hinder wound healing.

D. The client is using witch hazel pads on the perineum:

Witch hazel pads are commonly used for comfort and to alleviate swelling and discomfort in the perineal area after childbirth. While witch hazel pads can provide symptomatic relief, they are not typically associated with delayed wound healing when used appropriately. However, it's essential to ensure that the perineal area remains clean and dry to promote optimal wound healing and prevent complications.