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) "Your baby should wet 6 to 8 diapers per day":

This response is correct. One way to determine if a breastfed baby is getting enough milk is by monitoring the number of wet diapers. A newborn who is adequately breastfeeding typically wets at least 6 to 8 diapers per day, indicating sufficient fluid intake and adequate hydration.

B) "Your baby should sleep at least 6 hours between feedings":

This statement is inaccurate and does not provide an appropriate measure of whether the baby is getting enough breast milk. Newborns typically feed frequently, often every 2 to 3 hours, and it is normal for them to wake for feeds during the night. Using sleep patterns alone to assess feeding adequacy is not reliable and can lead to inadequate milk intake.

C) "Your baby should burp after each feeding":

While burping is a common practice after feeding to help prevent discomfort from trapped air, it is not an indicator of whether the baby is getting enough breast milk. Burping is more related to gastrointestinal comfort rather than feeding adequacy.

D) "Your baby should have a wake cycle of 30 to 60 minutes after each feeding":

This statement does not accurately assess feeding adequacy. While it's normal for babies to have awake periods after feeding, the duration of these wake cycles alone does not indicate whether the baby is getting enough breast milk. Monitoring diaper output and weight gain are more reliable indicators of feeding adequacy.

A) Ask the client to rate her pain:

Assessing the client's pain is important for overall postpartum care, but it does not directly address the issue of a slightly boggy and displaced fundus. Pain assessment should be done routinely but is not the priority in this situation.

B) Encourage the client to perform Kegel exercises:

Kegel exercises are beneficial for strengthening pelvic floor muscles but do not address the issue of a boggy and displaced fundus. While Kegel exercises can promote postpartum recovery, they are not the priority intervention in this case.

C) Assist the client to the bathroom to void:

This is the correct action. A boggy and displaced fundus may indicate urinary retention, which can contribute to uterine atony. Helping the client to the bathroom to void can relieve bladder distension, allowing the uterus to contract more effectively and reducing the risk of postpartum hemorrhage.

D) Encourage the client to move to the left lateral position:

Moving to the left lateral position can help improve uterine perfusion by relieving pressure on the vena cava, but it does not directly address the issue of urinary retention or a boggy fundus. While changing positions is generally beneficial postpartum, assisting the client to void takes precedence in this situation to address the potential cause of uterine atony.