A nurse in the delivery room is planning to promote maternal-infant bonding for a client who just delivered. What is the priority action by the nurse?

Choice A rationale
Infective endocarditis is an infection of the inner lining of the heart’s chambers or valves. It’s typically caused by bacteria entering the blood and settling in the heart. It is considered an acquired heart disease because it develops during a person’s lifetime.
Choice B rationale
Kawasaki disease is an illness that causes inflammation in arteries, veins, and capillaries. It’s most common in children younger than 5 years old. While it’s not a heart disease, it can lead to serious heart problems if not treated.
Choice C rationale
Hypoplastic left heart syndrome is a type of congenital heart defect, meaning it’s present at birth. Therefore, it’s not considered an acquired heart disease.
Choice D rationale
Cardiomyopathy is a disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body. It can be acquired or inherited.
Choice E rationale
Transposition of the great vessels is a serious but rare heart defect present at birth (congenital), in which the two main arteries leaving the heart are reversed (transposed). Therefore, it’s not considered an acquired heart disease.

Choice A rationale
The nurse should be concerned about a client with an 18kg (4 lb) weight gain in her first trimester. This is because the expected weight gain for a client in the first trimester is usually around 1.8 kg (4 lb)1. A weight gain of 18 kg in the first trimester significantly exceeds this expectation, which could indicate a potential health issue such as gestational diabetes or multiple pregnancies. It’s important for the nurse to report this finding to the healthcare provider for further evaluation and management.
Choice B rationale
A client with a 68 kg (15 lb) weight gain in her second trimester does not necessarily pose a concern. Weight gain during pregnancy varies among individuals and can be influenced by factors such as the mother’s body mass index (BMI) before pregnancy, the baby’s growth rate, and the mother’s diet and lifestyle. However, it’s always important to monitor weight gain throughout pregnancy to ensure it’s within a healthy range.
Choice C rationale
A client with a 13 kg (25 lb) weight gain in her third trimester does not necessarily pose a concern. Weight gain during the third trimester can be influenced by factors such as the baby’s growth rate, amniotic fluid volume, and the mother’s increased blood volume. However, it’s always important to monitor weight gain throughout pregnancy to ensure it’s within a healthy range.
Choice D rationale
A client with a 3.6 kg (8 lb) weight gain in her first trimester does not necessarily pose a concern. This is within the expected weight gain range for the first trimester. However, it’s always important to monitor weight gain throughout pregnancy to ensure it’s within a healthy range.