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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 A

Explanation

A. Obtain a prescription for a broad-spectrum antibiotic.

The client's fever (38.5°C), chills, abdominal pain, malodorous lochia, and tender fundus suggest a potential postpartum infection, such as endometritis. Administering a broad-spectrum antibiotic is necessary to treat the infection. Given the clinical scenario, the nurse should prioritize addressing the client's symptoms and signs that suggest infection and support her well-being postpartum. Here's a breakdown of the appropriate actions:

B. Initiate airborne isolation precautions.

  • Not necessary in this case. The client's symptoms and signs do not suggest an airborne infectious disease.

C. Place the client on strict bedrest.

  • This is not necessary. While rest is important, strict bedrest may not be required and could increase the risk of other complications, such as deep vein thrombosis (DVT).

D. Instruct the client to stop breastfeeding.

  • Not necessary unless there is a specific contraindication. Instead, the nurse can provide support and advice on managing engorgement and breastfeeding difficulties.

Correct Answer is B

Explanation

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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