A nurse is assisting with the care of a 19-year-old female client who is at 18 weeks of gestation in the emergency department.

Exhibits

Complete the diagram by selecting from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Choice A rationale

Fundus located to the right of the umbilicus requires intervention. This can indicate a full bladder, which can inhibit uterine contraction and increase the risk of postpartum hemorrhage.

Choice B rationale

A temperature of 37.8° C (100° F) is a common finding postpartum and usually does not require intervention unless it is accompanied by other signs of infection.

Choice C rationale

Deep tendon reflexes 2+ is a normal finding and does not require intervention. It indicates normal neuromuscular function.

Choice D rationale

A moderate amount of lochia rubra is expected postpartum and does not require intervention unless it is excessive or associated with other abnormal symptoms.

Choice A rationale

The newborn's legs flexing at the knees and hips when pressure is applied to the soles indicates the stepping reflex, an expected response.

Choice B rationale

Newborns do not typically keep their eyes closed when tapped on the forehead; this is not an expected reflex response.

Choice C rationale

The palmar grasp reflex, where the newborn's fingers curl around the nurse's finger, is an expected and normal finding in newborns, indicating healthy neurological function.

Choice D rationale

The rooting reflex, where the newborn turns their head when their cheek is touched, is expected and demonstrates feeding readiness and normal neural development. .