A nurse is updating the plan of care for a newborn who is undergoing phototherapy. Which of the following actions should the nurse include in the plan?

Choice A reason:

Expressions of excitement are an expected finding during the taking-in phase of maternal postpartum adjustment. This is the time of reflection for the woman because, within the 2 to 3-day period, the woman is passive and dependent on her healthcare provider or support person with some of the daily tasks and decision-making. The woman prefers to talk about her experiences during labor and birth and also her pregnancy. The taking-in phase provides time for the woman to regain her physical strength and organize her rambling thoughts about her new role.

Choice B reason:

Lack of appetite is not an expected finding during the taking-in phase of maternal postpartum adjustment. The woman is oriented primarily to her own needs and she primarily focuses on sleeping and eating. She may have increased appetite due to the energy expenditure during labor and delivery. Lack of appetite may indicate postpartum depression or other complications.

Choice C reason:

Eagerness to learn newborn care skills is not an expected finding during the taking-in phase of maternal postpartum adjustment. This is more characteristic of the taking-hold phase, which starts 2 to 4 days after delivery. The woman starts to initiate actions on her own and make decisions without relying on others. She starts to focus on the newborn instead of herself and begins to actively participate in newborn care.

Choice D reason:

Focus on the family unit and its members is not an expected finding during the taking-in phase of maternal postpartum adjustment. This is more indicative of the letting-go phase, which occurs when the woman finally accepts her new role and gives up her old role. This is the phase where postpartum depression may set in. Readjustment of the relationship is needed for an easy transition to this phase.

Choice A reason:

Hypertonia is not a characteristic of a preterm infant, but rather of a post-term infant. Hypertonia means increased muscle tone or stiffness, which is more common in infants who are overdue. Preterm infants have poor muscle tone and less subcutaneous fat.

Choice B reason:

Long toenails are also not a characteristic of a preterm infant but of a post-term infant. Long toenails indicate that the infant has grown beyond the expected gestational age. Preterm infants have short and brittle nails.

Choice C reason:

Lanugo is a characteristic of a preterm infant. Lanugo is fine, downy hair that covers the body of the fetus. It usually disappears by the 36th week of gestation, but preterm infants may still have it at birth.

Choice D reason:

Dry skin is not a characteristic of a preterm infant but of a post-term infant. Dry skin indicates that the infant has lost moisture and subcutaneous fat due to prolonged exposure to the amniotic fluid. Preterm infants have thin and transparent skin that may be covered by vernix caseosa, a white, cheesy substance that protects the skin from the amniotic fluid.