Exhibits

Question 2(B) Complete the following sentence by using the lists of options. The nurse should first

dropdown

before performing a heel stick, followed by

dropdown

.

Choice A rationale

Identifying that the newborn resembles oneself as a baby is a normal and positive aspect of maternal-infant attachment and bonding, representing the "taking-hold" phase of postpartum psychological adjustment, where the mother focuses on the infant and parental role. This demonstrates integration and is not considered a psychosocial concern warranting intervention, indicating healthy psychological adaptation.

Choice B rationale

Reporting fatigue and a desire to sleep is a physiological and expected finding in the immediate postpartum period, largely due to the physical exertion of labor, blood loss, and hormonal shifts. While rest is important, this is considered a normal physical adjustment and not a primary psychosocial concern indicative of maladaptation or mental health issues, unlike severe mood or attachment disturbances.

Choice C rationale

A lack of desire to feed the newborn can signify impaired maternal-infant bonding, emotional withdrawal, or a potential symptom of postpartum mood disorders, such as postpartum depression, which is a significant psychosocial concern. This finding deviates from the expected "taking-hold" phase where the mother is typically focused on caring for and interacting with the infant, necessitating further psychosocial assessment.

Choice D rationale

Discussing a desire to have more children is a normal expression of future family planning and generally indicates a positive, healthy adaptation to the current newborn and the role of motherhood. This thought process does not suggest any immediate psychosocial concern or distress and reflects forward-looking reproductive health considerations and positive family construction.

Choice A rationale

The American Academy of Pediatrics recommends that term newborns should be fed on demand or at least every 3 to 4 hours, which provides sufficient caloric intake for growth and prevents hypoglycemia. Formula is digested more slowly than breast milk, so offering a bottle every 3 to 3 1/2 hours is generally appropriate to meet the infant's nutritional needs and satisfy hunger cues. Regular feeding supports adequate weight gain, which is a critical developmental milestone in the neonatal period.

Choice B rationale

For the first few weeks, the nurse should instruct the guardian to wake a sleepy newborn if more than 4 hours have passed since the last feeding to prevent excessive weight loss and hypoglycemia, as their small glycogen stores are rapidly depleted. However, after the initial period and once the infant is feeding well and gaining weight appropriately (usually about 2 weeks old), night waking is typically not necessary.

Choice C rationale

Diluting ready-to-feed formula by adding filtered water is contraindicated because it reduces the caloric and nutrient density below required levels for the newborn's growth. The proper ratio of formula powder or concentrate to water is crucial for providing essential electrolytes, protein, and carbohydrates. Dilution can lead to water intoxication or hyponatremia and cause serious neurological complications due to electrolyte imbalance.

Choice D rationale

Prepared infant formula should be used or discarded within 24 hours if stored in the refrigerator, not 72 hours. Bacteria can rapidly proliferate in prepared formula, even under refrigeration, increasing the risk of gastrointestinal infection for the newborn. Formula ready-to-feed containers, once opened, should also be used within 24 to 48 hours or discarded to maintain optimal safety.