A nurse is caring for a client who is 1 hr postpartum and observes a large amount of lochia rubra and several small clots on the client's perineal pad.
The fundus is midline and firm at the umbilicus.
Which of the following actions should the nurse take?.

The correct answer is choice A. She did her perineal care independently.

Choice A rationale:

Taking the initiative for caring for her newborn independently while managing her own postpartum needs marks the taking-hold phase of infant bonding.

Choice B rationale:

Being eager to talk about her birth experience is more associated with the taking-in phase, not the taking-hold phase.

Choice C rationale:

Not asking for anything for pain all day is not a specific indicator of the taking-hold phase.

Choice D rationale:

Sitting and rocking her infant for long intervals is not a specific indicator of the taking-hold phase.

The correct answers are choices B, E, and F.

Choice A rationale:

Nausea with vomiting during the first trimester is a common symptom of pregnancy and does not need to be reported immediately to the health care provider.

Choice B rationale:

Sudden leakage of fluid during the second trimester could indicate premature rupture of membranes, which can lead to infection and preterm labor. This should be reported immediately.

Choice C rationale:

Urinary frequency in the third trimester is a common symptom of pregnancy due to the growing uterus putting pressure on the bladder.

Choice D rationale:

Backache during the second trimester is a common symptom of pregnancy as the body adjusts to the growing uterus.

Choice E rationale:

Lower abdominal pain with shoulder pain in the first trimester could indicate an ectopic pregnancy, which is a medical emergency and should be reported immediately.

Choice F rationale:

Headache with visual changes in the third trimester could indicate preeclampsia, a serious condition that can lead to seizures, stroke, and other complications. This should be reported immediately.