A nurse is collecting data from a newborn who was delivered at 40 weeks of gestation.
Which of the following is an expected finding when eliciting reflexes from the newborn?

Choice A rationale

Placing tennis balls on the sacral area and leaning against them is a technique generally used to apply counter-pressure to the lower back. This method is effective for relieving the discomfort of back labor, where the fetal occiput is pressing on the mother's sacrum. It is a mechanical pain relief strategy, not acupressure, which involves applying pressure to specific anatomical points (meridians) to stimulate the body's natural pain-relieving mechanisms, such as endorphin release.

Choice B rationale

The instruction to "recognize specific signals, respond, and relax" aligns with the basic principles of acupressure use during labor. Acupressure is an intervention where the client applies sustained pressure to specific acupuncture points, which requires paying attention to the onset and intensity of contractions (signals) to effectively time the pressure application (respond) and then concentrating on relaxation techniques. This mind-body connection enhances the pain-relieving effect by stimulating endorphin release and reducing muscular tension during labor contractions.

Choice C rationale

Using light, rhythmic stroking on the abdomen while breathing is a comfort measure known as effleurage. This technique is often taught as part of prepared childbirth methods, like Lamaze, to distract the woman from the pain of contractions through cutaneous stimulation. Effleurage is a form of light touch massage, fundamentally different from acupressure, which requires deep, sustained pressure on specific points to achieve its therapeutic effect, such as modulating pain perception.

Choice D rationale

Hydrotherapy, or immersing oneself in warm water, is a widely used non-pharmacological comfort measure in labor. The warm water promotes muscle relaxation, reduces the perception of pain through buoyancy and warmth, and can increase the production of natural pain relievers (endorphins). This method provides systemic relief and is entirely distinct from acupressure, which relies on targeted, localized pressure at specific anatomical points to manage labor discomfort.

Choice A rationale

Applying warm, moist packs is generally used to promote circulation and relieve discomfort associated with an already-formed thrombus or thrombophlebitis, not as a primary prophylactic measure. Prevention centers on enhancing venous return and inhibiting clot formation, whereas heat application may slightly increase local vasodilation and is not the most effective primary preventative method in the immediate postpartum period.

Choice B rationale

Elastic stockings (anti-embolism stockings) apply external graduated compression to the legs. This compression aids in increasing the velocity of venous blood flow and reducing venous stasis, particularly in the lower extremities, thereby reducing the risk of Deep Vein Thrombosis (DVT) and subsequent thrombophlebitis, especially important when the client is at rest or in bed.

Choice C rationale

Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen are used primarily for pain management and reducing inflammation. While some NSAIDs possess mild antiplatelet effects, this is not their primary indication, nor is it a sufficiently robust measure to be considered a key intervention for preventing thrombophlebitis in the postpartum period, which necessitates focused mechanical or pharmacological prophylaxis.

Choice D rationale

Ambulation is crucial as it promotes muscle contraction of the lower extremities (the skeletal muscle pump), which mechanically compresses the deep veins and forces blood back toward the heart. This action significantly increases venous return, prevents venous stasis, and activates endogenous fibrinolysis, making early and frequent ambulation a cornerstone of thrombophlebitis prevention.