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?
Prepare for a cesarean birth.
Administer IV antibiotic prophylaxis.
Obtain a vaginal culture.
Administer metronidazole orally
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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Correct Answer is B
Explanation
Choice A rationale
During labor, the body experiences physiological stress, which typically causes an increase, not a decrease, in white blood cell (WBC) count. This increase is a normal response to stress.
Choice B rationale
Blood glucose levels can decrease during labor due to the energy expenditure and physiological demands of the process. This is why it is important to monitor glucose levels and provide necessary interventions if hypoglycemia occurs.
Choice C rationale
The respiratory rate generally increases during labor to meet the increased oxygen demands of the body. A decrease in respiratory rate is not expected during this time.
Choice D rationale
Body temperature may increase slightly during labor due to the physical exertion and metabolic activity involved. A decrease in temperature is not a typical finding during labor.
Correct Answer is B
Explanation
Choice A rationale
Variable decelerations are associated with umbilical cord compression, not placenta previa. In placenta previa, the placenta covers the cervical os, but it does not typically cause
variable decelerations on fetal monitoring.
Choice B rationale
Painless vaginal bleeding is a hallmark sign of placenta previa. This occurs because the placenta is located near or over the cervical os, leading to bleeding when the cervix dilates
or effaces.
Choice C rationale
A rigid abdomen is more indicative of placental abruption, where the placenta detaches prematurely from the uterine wall, causing pain and a tense abdomen, not typically seen in
placenta previa.
Choice D rationale
Uterine tachysystole is characterized by excessive uterine contractions and is not a clinical finding related to placenta previa. Tachysystole often results from excessive oxytocin use
or other uterine stimulants.