A nurse is caring for a newborn and assessing newborn reflexes. To elicit the Moro reflex, the nurse should take which of the following actions?

A) Orthostatic hypotension:

Orthostatic hypotension, although it can occur postpartum due to changes in fluid volume and hormone levels, is not typically an immediate sign of a postpartum complication. It may occur as the body adjusts to changes after delivery but is not necessarily indicative of a complication on its own.

B) Heart rate 110/min:

A heart rate of 110/min is elevated and may indicate a postpartum complication such as hemorrhage, infection, or other cardiovascular issues. An elevated heart rate can be a sign of physiological stress or inadequate perfusion, requiring further assessment and intervention by the nurse.

C) Fundus palpable at the umbilicus:

A fundus palpable at the umbilicus is a normal finding for a client who is 12 hr postpartum. Immediately after delivery, the fundus is typically firm and located at or just below the level of the umbilicus. Over time, it should descend and become firmer as the uterus involutes.

D) Urine output of 3,000 mL in 12 hr:

An unusually high urine output of 3,000 mL in 12 hr may indicate excessive fluid loss, which could be a sign of postpartum hemorrhage. While it is essential for postpartum clients to void frequently to prevent urinary retention, such a high output warrants further investigation by the nurse to rule out complications.

A) Shivering:

Shivering is a physiological response to cold in which the body generates heat through involuntary muscle contractions. Placing a newborn under a radiant heat warmer helps prevent shivering by maintaining the infant's body temperature within a normal range, reducing the need for compensatory mechanisms such as shivering.

B) Basal metabolic rate reduction:

Basal metabolic rate reduction is not the primary purpose of placing a newborn under a radiant heat warmer. While radiant heat helps maintain body temperature, it does not directly affect the basal metabolic rate, which is the body's energy expenditure at rest.

C) Cold stress:

Placing a newborn under a radiant heat warmer helps prevent cold stress by providing a controlled environment that maintains the infant's body temperature within a normal range. Cold stress occurs when a newborn's body temperature falls below normal, leading to increased oxygen and glucose consumption, metabolic acidosis, and potential complications such as respiratory distress and hypoglycemia.

D) Brown fat production:

Brown fat production is a physiological response to cold exposure in newborns. Brown fat is a specialized type of fat tissue that generates heat when metabolized, helping newborns maintain body temperature during cold exposure. While brown fat production is important for thermoregulation in newborns, placing the infant under a radiant heat warmer primarily aims to prevent cold stress by providing external warmth, rather than stimulating brown fat production.