A nurse is caring for a newborn whose father voices concerns about his ability to bond with his baby. Which of the following actions should the nurse take to facilitate bonding? (Select all that apply.)

Choice A rationale:

Assisting the client to void is a priority intervention in this situation. A full bladder can displace the uterus and prevent it from contracting effectively, leading to a boggy and high- positioned fundus. After the client empties her bladder, the nurse should reassess the fundus to ensure it has descended to its appropriate location, which is usually at or just below the level of the umbilicus.

Choice B rationale:

Documenting the findings as within normal limits is incorrect because a firm, displaced fundus that is 3 cm above the umbilicus is not considered normal. This finding indicates that the uterus is not contracting adequately, and the nurse should take appropriate actions to address the issue.

Choice C rationale:

Gently massaging the client's fundus is not the correct intervention in this case. Massaging a firm fundus could cause uterine irritation and should be avoided. Instead, the nurse should encourage the client to empty her bladder, which often helps the uterus contract and descend to its proper position.

Choice D rationale:

Encouraging the client to ambulate may be helpful in some cases to promote uterine contractions and involution. However, in this situation, the priority is to address the full bladder, as it is a common cause of a displaced and high fundus shortly after delivery.

Choice A rationale:

The nurse should plan to administer Ampicillin to the client with a group B streptococcus (GBS) B-hemolytic infection. Ampicillin is the first-line antibiotic treatment for intrapartum prophylaxis in GBS-positive pregnant women. It helps prevent the transmission of the bacteria from the mother to the newborn, reducing the risk of early-onset GBS infection in the infant.

Choice B rationale:

Azithromycin is not the appropriate choice for treating GBS B-hemolytic infection during labor. While Azithromycin is effective against certain bacteria, it is not the recommended antibiotic for GBS prophylaxis in labor. Ampicillin or Penicillin is the preferred medication in this scenario.

Choice C rationale:

Ceftriaxone is not the appropriate medication for treating GBS B-hemolytic infection during labor. Ceftriaxone belongs to the cephalosporin class of antibiotics and is not the first-line treatment for GBS prophylaxis. Ampicillin or Penicillin is the preferred choice.

Choice D rationale:

Acyclovir is an antiviral medication and is not indicated for the treatment of GBS B-hemolytic infection. GBS is a bacterial infection, and antiviral medications like Acyclovir do not have an effect on bacteria.