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
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 A
Explanation
Choice A rationale
Music can be a non-pharmacological method to help manage pain and anxiety during the latent phase of labor.
Choice B rationale
Biofeedback might be helpful but can be challenging to implement without prior training.
Choice C rationale
Administering fentanyl 100 mg every hour is not appropriate; fentanyl is typically administered in much smaller doses.
Choice D rationale
A pudendal nerve block is usually reserved for the second stage of labor or delivery, not the latent phase.