Which newborn reflex is elicited by stroking the lateral sole of the infant's foot from the heel to the ball of the foot?

Choice A rationale

A displaced fundus from the midline, often deviated to the right and boggy, suggests a full bladder interfering with uterine contraction and involution. A distended bladder prevents the uterus from clamping down effectively, increasing the risk of postpartum hemorrhage. Immediate intervention is required to assist the client in emptying her bladder, which should allow the uterus to return to the midline and contract firmly.

Choice B rationale

A fundal height below the umbilicus on the first postpartum day is a normal finding. Following delivery, the uterus begins to descend approximately one fingerbreadth (1 cm) per day. Therefore, a fundus below the umbilicus at 24 hours postpartum indicates normal uterine involution.

Choice C rationale

A decreased urge to void is common in the immediate postpartum period due to factors such as perineal swelling, pain, and the effects of anesthesia. While it's important to monitor urinary output, a decreased urge to void in the first 24 hours is not typically considered a finding requiring immediate intervention unless accompanied by other signs of urinary retention or bladder distension.

Choice D rationale

Increased urine output is also a normal finding in the postpartum period as the body eliminates excess fluid volume accumulated during pregnancy. Diuresis typically begins within 12 to 24 hours after delivery and can last for several days. This is a physiological process and does not require immediate intervention.

Choice A rationale

The 1-hour glucose tolerance test is typically performed between 24 and 28 weeks of gestation to screen for gestational diabetes. This screening involves measuring the client's blood glucose level one hour after consuming a 50-gram glucose load. A normal result is generally considered to be a blood glucose level below 130-140 mg/dL.

Choice B rationale

Rubella titer is usually assessed early in pregnancy, ideally during the first prenatal visit, to determine the woman's immunity to rubella. If the woman is not immune, vaccination is typically offered postpartum to prevent infection in subsequent pregnancies, as rubella infection during pregnancy can cause serious congenital defects.

Choice C rationale

Sexually transmitted disease testing is ideally conducted at the initial prenatal visit to identify and treat any infections early in pregnancy, reducing the risk of transmission to the fetus and other complications. While repeat testing may be indicated based on risk factors, it is not a routine test specifically scheduled for the 24-week appointment for all clients.

Choice D rationale

Group B Streptococcus (GBS) culture is typically performed later in pregnancy, usually between 35 and 37 weeks of gestation, to determine if the woman is colonized with GBS. This is important for intrapartum management to prevent neonatal GBS infection.