When the infant's toes hyperextend and the big toe dorsiflexes when sole of foot is stroked. This Reflex is called

A) Have the client void, then reassess the fundus:
A fundus that is firm but shifted to the right of the midline is a common sign of bladder distention. After childbirth, the bladder may fill with urine, which can displace the uterus and cause it to deviate from the midline, typically to the right. The first step in managing this situation is to have the client void to relieve the bladder distention, which often resolves the uterine shift. Once the bladder is empty, the nurse should reassess the fundus to see if the position returns to midline and remains firm. This is a non-invasive and effective initial intervention.

B) Encourage the client to ambulate:
Encouraging the client to ambulate could be beneficial for overall recovery, but it is not the priority action in this case. The issue at hand is a shifted fundus likely due to bladder distention, which should be addressed by encouraging the client to void first. Ambulation can be considered later when the immediate concern of bladder distention is managed.

C) Notify the healthcare provider:
While notifying the healthcare provider may be necessary if the issue persists after voiding or if there are other signs of complications, it is not the first step. The nurse should first attempt to resolve the issue through bladder emptying, as this is the most common cause of the shift in the fundus. If the problem persists after this, then further steps, including notifying the healthcare provider, would be appropriate.

D) Obtain an order for oxytocin:
Oxytocin is typically administered to help with uterine contraction and involution. However, since the fundus is firm and the primary issue appears to be bladder distention, administering oxytocin is not indicated at this time. The priority is to address the likely cause of the fundus being shifted, which is a full bladder. If the issue persists after voiding, then further intervention such as administering oxytocin may be considered.

A) Mother Rh-, baby Rh+:
RhoGAM (Rh immune globulin) is administered to a mother who is Rh-negative and has delivered a baby who is Rh-positive. If the Rh-negative mother is exposed to Rh-positive blood (via the baby’s blood during delivery), her immune system may start producing antibodies against Rh-positive cells, which could affect future pregnancies. The RhoGAM injection works by preventing the mother from developing these antibodies, thereby protecting any subsequent pregnancies from hemolytic disease of the newborn (HDN) in which the mother’s antibodies attack the baby’s red blood cells. This is a crucial preventive measure to avoid sensitization to Rh-positive blood.

B) Mother Rh-, baby Rh-:
If both the mother and baby are Rh-negative, there is no concern about the development of antibodies because there is no exposure to Rh-positive blood. Therefore, RhoGAM is not necessary in this situation.

C) Mother Rh+, baby Rh+:
In this scenario, the mother is Rh-positive, so she cannot develop antibodies against Rh-positive blood, regardless of the baby's Rh status. Hence, RhoGAM is not required because there is no risk of Rh incompatibility.
D) Mother Rh+, baby Rh-:
Since the mother is Rh-positive, there is no risk of her immune system attacking an Rh-negative baby’s red blood cells. Thus, RhoGAM is not needed in this case either.