Which of the following is an example of a primitive reflex that is present in newborns and typically disappears by 3-4 months of age?

A) At the umbilicus:
After delivery, the fundus is typically located at or just below the umbilicus in the immediate postpartum period, but it will gradually descend over the next few days. By 8 hours postpartum, the fundus is often slightly below the umbilicus, not directly at the umbilicus. The fundus will continue to shrink in size and move downward toward the pelvic region as the uterus contracts and involutes.

B) At a non-palpable depth:
A fundus that is non-palpable is generally expected later in the postpartum period, typically by 10-14 days after delivery, as the uterus contracts and returns to its pre-pregnancy size. At 8 hours postpartum, the fundus is still palpable, generally just below the umbilicus, and should be evaluated for firmness and position.

C) Just above the symphysis pubis:
The fundus is usually higher than the symphysis pubis at 8 hours postpartum, as it is still in the process of descending from the higher position it occupied during pregnancy. It would be expected to be just below the umbilicus or about 1 to 2 finger widths below it. By the second or third day postpartum, the fundus begins to move lower toward the symphysis pubis as it continues to involute.

D) Just below the umbilicus:
Eight hours after delivery, the nurse should expect to palpate the fundus just below the umbilicus. This is a typical finding as the uterus begins to contract and shrink after the delivery of the placenta. The fundus will descend about 1-2 cm per day postpartum, so by 8 hours, it is usually just slightly below the level of the umbilicus.

A) Dry and stimulate newborn with towel:
Drying and stimulating the newborn immediately after birth is a standard practice to prevent heat loss and promote early bonding. This action helps to prevent heat loss through evaporation and stimulates the newborn to breathe. It is an appropriate intervention to reduce the risk of hypothermia, not increase it.

B) Place a hat on the newborn's head:
Placing a hat on the newborn’s head is an appropriate and helpful intervention. Since a significant amount of heat is lost through the head, especially in newborns who have a larger surface area relative to their body mass, keeping the head covered with a hat helps to retain warmth and reduce the risk of hypothermia. This would not place the newborn at risk for hypothermia.

C) Maintain the delivery room temperature at 20° C (68° F):
A delivery room temperature of 20° C (68° F) is on the lower end of the recommended range for newborn care. Newborns are particularly susceptible to heat loss due to their high surface area-to-body weight ratio and immature thermoregulation system. A cooler environment like 20°C increases the risk of hypothermia, as the newborn will lose heat more quickly than it can generate on its own.

D) Place a blanket on top of maternal and newborn:
Placing a blanket over the mother and newborn is an appropriate intervention to prevent heat loss. This promotes warmth by reducing heat loss from the newborn's body surface to the cooler environment. This would not place the newborn at risk for hypothermia; instead, it helps to maintain body temperature.