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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 D

Explanation

Choice A rationale

Transient circumoral cyanosis is common in newborns, especially when crying or feeding, and usually resolves on its own without intervention.

Choice B rationale

Transient strabismus, or the temporary crossing of the eyes, is normal in newborns due to underdeveloped eye muscles and usually resolves as the infant grows.

Choice C rationale

Caput succedaneum is the swelling of the scalp caused by pressure during delivery. It is usually benign and resolves within a few days without treatment.

Choice D rationale

Generalized petechiae, or small red or purple spots on the skin, can indicate a serious underlying condition such as a clotting disorder or infection and requires immediate medical evaluation.

Correct Answer is ["B","C","D","E","F"]

Explanation

A. "I will inject this medication under your skin.": Tocolytic medications are typically administered orally, intravenously, or intramuscularly, not subcutaneously.

B. "You may experience a headache after receiving this medication."
Some tocolytic medications can cause headaches as a side effect.


C. "It is common for this medication to make you feel jittery."
Tocolytic medications, such as terbutaline, can cause nervousness or jitteriness.

D. "This medication should decrease your contractions."
The primary purpose of tocolytic medication is to decrease uterine contractions and delay preterm labor.


E. "I'll check your reflexes frequently while you are receiving this medication."
Some tocolytic medications, like magnesium sulfate, require monitoring of deep tendon reflexes to assess for potential toxicity.


F. "This medication can make your heart beat faster."
Tocolytic medications, such as terbutaline, can increase heart rate.


G. "This medication can increase your blood pressure.":

Some tocolytic medications, like magnesium sulfate, can actually lower blood pressure rather than increase it.

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