A client arrives at OB triage with complaints of decreased fetal movement for the past 24 hours.
The client states, "I see the high-risk clinic because I have chronic hypertension and gestational diabetes.”. The nurse applies the external fetal monitors and identifies a fetal heart rate baseline of 120 bpm, absent variability, no accelerations, and recurrent late decelerations.
What fetal heart rate category would the nurse communicate to the provider?

Based on the provided information:

1. Boggy fundus: This indicates uterine atony, which is a primary cause of postpartum hemorrhage. Addressing this immediately is crucial to prevent excessive bleeding.
2. Heavy lochia with small clots: This further supports the concern for postpartum hemorrhage, necessitating prompt attention to assess and manage the bleeding.

Therefore, the nurse should first address the client's Fundus (Option A) followed by the client's Lochia (Option C).

So, the completed sentence would be:

"The nurse should first address the client's Fundus followed by the client's Lochia."

Choice A rationale

Turning the newborn's head quickly to one side elicits the tonic neck reflex, not the Moro reflex. The tonic neck reflex involves the newborn's arm extending on the side where the head is turned and the opposite arm bending at the elbow, resembling a fencing position.

Choice B rationale

Performing a sharp hand clap near the infant elicits the Moro (startle) reflex, which is characterized by the infant throwing their arms outward, opening their hands, and then bringing the arms back in. This is a response to sudden stimuli and is a normal reflex in newborns.

Choice C rationale

Stroking the outer edge of the sole of the foot from near the heel up toward the toes elicits the Babinski reflex, not the Moro reflex. The Babinski reflex is characterized by the big toe moving upward or toward the top surface of the foot and the other toes fanning out.

Choice D rationale

Placing a finger at the base of the newborn's toes elicits the plantar grasp reflex, not the Moro reflex. The plantar grasp reflex involves the toes curling around the finger or object placed at the base of the toes. .