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

Choice A rationale
Puncturing the lateral side of the heel is the correct procedure when performing a heel stick on a newborn. This area is less likely to come into contact with hard surfaces that could cause injury to the puncture site.
Choice B rationale
A 21-gauge needle is too large for a heel stick procedure on a newborn. A smaller gauge needle or a lancet is typically used to ensure the puncture is as small and painless as possible.
Choice C rationale
Applying an alcohol pad to the site after the procedure is not recommended. Alcohol can cause skin irritation and dryness. Instead, a sterile gauze or bandage is usually applied to stop any bleeding from the puncture site.
Choice D rationale
Placing a cold cloth at the site for 15 minutes before the procedure is not recommended. Cold can cause vasoconstriction, which would make it more difficult to obtain a blood sample.
Instead, warming the heel prior to the stick can help to increase blood flow to the area.

Choice A rationale
Taking charge of all mothering tasks is more indicative of the “taking-hold” phase, which typically occurs a few days after birth.
Choice B rationale
Desiring privacy with the newborn is not specifically indicative of the “taking-in” phase.
Choice C rationale
Putting personal needs aside is not specifically indicative of the “taking-in” phase.
Choice D rationale

Reviewing the birth experience with others is indicative of the “taking-in” phase. During this phase, the new mother is often passive and somewhat dependent, and she may need to review her childbirth experience as a way to fully grasp her new role.