A woman gave birth to a 7-lb, 3-ounce infant boy 2 hours ago. The nurse determines that the woman's bladder is distended because her fundus is now 3 cm above the umbilicus and to the right of the midline. In the immediate after birth period, the most serious consequence likely to occur from bladder distention is:

A) Manual Expression:
Manual expression is an excellent way to show a new mother that she does have milk or colostrum. By gently massaging and expressing the breast, the mother can see or feel the small amount of colostrum being released. This helps reassure her that milk production has begun, even if it’s not abundant right away. Colostrum is often produced in small amounts during the first few days postpartum, and learning how to express it can provide immediate visual confirmation that milk is available for the baby.

B) Massaging breast to bring milk to the nipple:
While massaging the breast can help facilitate the milk ejection reflex (let-down), it doesn’t necessarily show the mother that she has milk. The milk flow may not be immediately visible without manual expression. The process of massaging can help increase milk flow over time but is not the most effective way to demonstrate the presence of colostrum in the immediate postpartum period.

C) Using a nipple shield:
A nipple shield can sometimes be used to help babies latch more effectively if there are latch issues, but it won’t directly show the mother that she has milk or colostrum. In fact, frequent use of a nipple shield without proper latching technique can interfere with establishing breastfeeding. It’s more important to help the mother with proper latching and positioning, along with demonstrating manual expression.

D) Keeping infant skin to skin:
Skin-to-skin contact is incredibly beneficial for bonding and promoting breastfeeding, as it stimulates the release of oxytocin and encourages the baby to latch. However, it does not directly show the mother that she has milk or colostrum. While it can help initiate milk production, manual expression provides a more direct and immediate way to demonstrate that milk is available.

A) 2 to 3 oz (60 to 90 mL):
To determine the appropriate amount of formula for this infant, first calculate the total fluid requirements for the day. The infant weighs 6 lb (2722 g), and newborns typically need 73 mL of fluid per pound of body weight per day.
6 lb × 73 mL = 438 mL of fluid required daily.
Since the infant is fed every 4 hours, this equates to approximately 6 feedings in a 24-hour period.
438 mL ÷ 6 feedings = 73 mL per feeding.
Converting this to ounces (since 1 oz = 30 mL), the infant would need about 2.5 oz per feeding. Therefore, 2 to 3 oz (60 to 90 mL) per feeding is appropriate to meet the infant's daily fluid needs.

B) 1 to 1.5 oz (30 to 45 mL):
This amount is insufficient for the infant’s daily fluid needs. At 1 to 1.5 oz per feeding, the total intake for the day would be only 180 to 270 mL, which is well below the required 438 mL. This could lead to dehydration and inadequate nourishment.

C) 4 to 5 oz (120 to 150 mL):
This amount is excessive for a 3-day-old infant. Newborns typically consume much smaller amounts at each feeding due to their smaller stomach capacity. Overfeeding could lead to discomfort and potential digestive issues.

D) 3 to 4 oz (90 to 120 mL):
While this range is closer to the required amount, it is still slightly too much for a 3-day-old infant. At this age, the recommended amount is closer to 2.5 oz per feeding, so 3 to 4 oz may be excessive and could contribute to overfeeding, which might be uncomfortable for the infant.