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 D
Explanation
Choice A rationale
Only one dose of rubella immunization is necessary post-delivery, no need for a second dose in 2 weeks.
Choice B rationale
Prevention of pregnancy is recommended for at least 1 month (not 4 months) after receiving the rubella vaccine to avoid possible teratogenic effects.
Choice C rationale
An additional rubella immunization is not recommended during pregnancy as the live vaccine is contraindicated during gestation.
Choice D rationale
Rubella vaccine is safe for breastfeeding mothers, as it does not affect the safety of breast milk.
Correct Answer is A
Explanation
Choice A rationale
Checking fetal heart tones is the priority to assess the well-being of the fetus, especially in breech presentation and after the membranes have ruptured.
Choice B rationale
Preparing for a cesarean birth is important but follows the assessment of fetal heart tones and other immediate measures.
Choice C rationale
Checking the color, amount, and odor of the fluid is important, but ensuring fetal heart tones comes first to monitor any distress.
Choice D rationale
Performing a Nitrazine test to assess for rupture of membranes is redundant once the client reports her water has broken.