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A nurse is admitting a client who is at 9 weeks of gestation and in active labor when screened at 6 weeks of gestation.
Which of the following actions should the nurse take?

A.

Prepare for a cesarean birth.

B.

Administer IV antibiotic prophylaxis.

C.

Obtain a vaginal culture.

D.

Administer metronidazole orally

Answer and Explanation

The Correct Answer is B

Choice A rationale

Preparing for a cesarean birth is not an immediate necessity unless there are complications that warrant such intervention. Cesarean births are typically reserved for situations where

vaginal delivery poses a risk to the mother or the baby.

 

Choice B rationale

Administering IV antibiotic prophylaxis is critical in preventing potential infections during the labor process, especially given the early gestation period. This helps in safeguarding both

the mother and the fetus from infections like group B streptococcus.

 

Choice C rationale

Obtaining a vaginal culture is generally done to check for infections such as bacterial vaginosis or sexually transmitted infections. However, it is not an immediate priority when the

patient is already in active labor.

 

Choice D rationale

Administering metronidazole orally is used to treat bacterial infections but is not an immediate action required in this scenario. Metronidazole may not be the most suitable choice

during labor as it does not provide immediate infection prevention.


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View Related questions

Correct Answer is C

Explanation

Choice A rationale

Giving glucose water after feedings is not recommended for newborns undergoing phototherapy. Breastfeeding or formula feeding should be continued to provide adequate nutrition and hydration.

Choice B rationale

Instructing the client to avoid breastfeeding during treatment is not necessary. Breastfeeding should continue to promote bonding, provide nutrition, and help with the infant's hydration and bilirubin excretion.

Choice C rationale

Monitoring intake and output is crucial for a newborn receiving phototherapy to ensure proper hydration and assess the effectiveness of the treatment in lowering bilirubin levels.

Choice D rationale

Applying lotions and ointments throughout the treatment is not recommended, as they can interfere with the effectiveness of phototherapy. The skin should be clean and dry to maximize exposure to the phototherapy light.

Correct Answer is A

Explanation

Choice A rationale

Rear-facing car seats are safer for infants and toddlers because they provide better support for their head, neck, and spine in the event of a collision. The American Academy of Pediatrics recommends keeping children in rear-facing seats until they are at least 2 years old or until they reach the highest weight or height allowed by the manufacturer.

Choice B rationale

A four-point harness is not sufficient for securing a baby in a car seat. A five-point harness, which includes two shoulder straps, two hip straps, and one crotch strap, provides more secure and effective restraint for infants.

Choice C rationale

The shoulder harness should be positioned in the slots at or below the baby's shoulders, not above, to ensure proper fit and restraint. Placing the harness above the shoulders can result in improper restraint and increased risk of injury in an accident.

Choice D rationale

The correct angle for a rear-facing car seat is typically 45 degrees, not 30 degrees. A 45-degree angle ensures the baby's airway remains open, preventing the head from falling forward and potentially causing breathing difficulties.

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