A nurse is performing a physical examination of a term newborn upon admission to the nursery.
In which order should the nurse perform the following assessments?

A. The bladder is distended upon palpation: A distended bladder suggests urinary retention, not effective voiding. This may impair uterine contraction and increase the risk of hemorrhage.
B. The uterine fundus is 2 cm above the umbilicus: A high-rising fundus may indicate a full bladder that is displacing the uterus, often due to incomplete voiding.
C. The client does not feel the urge to urinate: Lack of urge may indicate altered bladder sensation, a potential complication after catheter removal and childbirth.
D. The client urinates 30 mL/hr: Urine output of ≥30 mL/hr is considered adequate and reflects effective voiding and kidney function, especially in the postpartum period.

Choice A rationale

Consuming 27 mg of iron daily is within the recommended intake for pregnant individuals, which is typically around 27 mg per day. Iron is crucial for fetal growth and preventing maternal anemia, and this intake level supports healthy pregnancy outcomes, indicating a reduced risk factor.

Choice B rationale

Consuming 300 mg of caffeine daily is considered a high-risk lifestyle factor during pregnancy. High caffeine intake is associated with an increased risk of miscarriage, preterm birth, and low birth weight infants. The recommended limit for pregnant individuals is generally below 200 mg per day to mitigate these risks.

Choice C rationale

Consuming 3 L (101 oz) of water daily is a healthy practice during pregnancy. Adequate hydration is essential for maintaining blood volume, amniotic fluid levels, and preventing constipation and urinary tract infections. This intake level supports maternal and fetal health.

Choice D rationale

Consuming 400 mcg of folate daily is the recommended intake for pregnant individuals, particularly in the periconceptional period. Folic acid supplementation significantly reduces the risk of neural tube defects in the fetus, promoting a healthy pregnancy outcome and indicating a reduced risk factor.