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) Fundal height below the umbilicus:

In the immediate postpartum period, the fundus typically descends at a predictable rate. A fundal height below the umbilicus on the first day postpartum is expected. It is not a cause for immediate intervention unless accompanied by other signs of postpartum hemorrhage.

B) Decreased urge to void:

A decreased urge to void is common in the immediate postpartum period due to perineal swelling, episiotomy or lacerations, and the effects of regional anesthesia. However, it is not an immediate concern as long as the client is voiding adequate amounts of urine.

C) Increased urine output:

Increased urine output in the postpartum period is expected due to the diuretic effect of the body eliminating excess fluid retained during pregnancy. It is not a cause for immediate intervention as long as the client is not exhibiting signs of dehydration.

D) Displaced fundus from the midline:

A displaced fundus from the midline is concerning as it may indicate uterine atony, which is the most common cause of postpartum hemorrhage. Immediate intervention is necessary to prevent further complications such as excessive bleeding.

A) Notify the client's provider:

There is no indication to notify the provider at this time. The presence of lochia rubra with small clots and a firm, midline fundus at the umbilicus indicates typical postpartum bleeding and uterine involution. This finding does not warrant immediate notification of the provider.

B) Encourage the client to empty her bladder:

Encouraging the client to empty her bladder is essential for promoting uterine contractions and preventing uterine atony. However, in this scenario, the fundus is already midline and firm, suggesting that bladder distension is not the cause of the excessive bleeding. While voiding may help, it is not the priority action.

C) Increase the frequency of fundal massage:

Increasing the frequency of fundal massage may not be necessary in this situation since the fundus is already midline and firm, indicating adequate uterine contractions. Fundal massage is typically performed if the fundus is boggy or if there is excessive bleeding.

D) Document the findings and continue to monitor the client:

This is the correct action. Documenting the assessment findings, including the amount and character of lochia, presence of clots, and fundal height, is essential for ongoing monitoring and evaluation of the client's postpartum recovery. Continuing to monitor the client allows the nurse to detect any changes in condition that may require further intervention.