The nurse should further evaluate the cry characteristics, muscle tone, and respiratory characteristics to determine if the newborn is experiencing a complication.

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

Neonatal hypoglycemia is typically defined as a blood glucose concentration below 40 mg/dL in the first 4 hours of life, or below 45 mg/dL between 4 and 24 hours. Glucose levels of 40 to 45 mg/dL are generally considered the goal range to prevent neurological injury, not the normal lower limit for up to 72 hours post-birth.

Choice B rationale

If a newborn's blood glucose levels remain persistently below 40 mg/dL after initial management (like feeding) or if they develop symptomatic hypoglycemia, intravenous dextrose will be required. A value persistently below 50 mg/dL is concerning, but the 40 mg/dL threshold is often the critical point for initiating IV glucose when oral methods fail.

Choice C rationale

The umbilical cord provides the fetus with a continuous supply of glucose via the placenta from the mother. Upon umbilical cord clamping, this maternal glucose supply is abruptly interrupted, requiring the newborn's immature metabolic systems to take over glucose homeostasis. This sudden loss of exogenous glucose is a primary factor in transient newborn hypoglycemia.

Choice D rationale

Frequent breastfeeding provides the newborn with a readily available source of lactose, which is metabolized into glucose, thereby promoting the stability of their blood glucose levels. Early and frequent feeding is the primary intervention for transient hypoglycemia in newborns who are able to feed, utilizing the oral route for caloric intake.

Choice E rationale

Transient hypoglycemia is a common and expected physiological adaptation in term newborns during the initial hours after birth. The abrupt cessation of maternal glucose supply necessitates the newborn's activation of gluconeogenesis and glycogenolysis, which may temporarily be insufficient, leading to a mild, self-limiting drop in blood glucose.

Choice F rationale

Skin-to-skin contact immediately after birth is vital as it prevents cold stress. When a newborn is cold, they must expend energy (calories) to produce heat, which consumes glucose, potentially leading to or exacerbating hypoglycemia. Thermoregulation thus indirectly stabilizes blood glucose levels by conserving energy.