A nurse is assisting in the care of a client who is in labor and requires intermittent fetal monitoring. Which of the following actions should the nurse take?
Auscultate fetal heart tones during a contraction.
Place a Doppler ultrasound over the fundus.
Perform Leopold maneuvers to determine fetal position.
Count the fetal heart rate for 15 seconds.
The Correct Answer is C
Choice A rationale
Auscultating fetal heart tones during a contraction does not provide a clear assessment of the fetal heart rate pattern and can be affected by the contraction itself.
Choice B rationale
Placing a Doppler ultrasound over the fundus is not effective, as the fundus is not the optimal location to hear fetal heart tones, especially in early labor.
Choice C rationale
Performing Leopold maneuvers to determine fetal position is crucial as it helps in placing the Doppler in the correct position for accurate monitoring of fetal heart tones.
Choice D rationale
Counting the fetal heart rate for 15 seconds and then multiplying by 4 may not provide an accurate assessment of the fetal heart rate pattern or variability, which is important for fetal well-being assessment. .
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Correct Answer is D
Explanation
Choice A rationale
Mongolian spots are common, benign skin markings that some newborns have, but they are not related to rubella exposure during pregnancy.
Choice B rationale
Jaundice is a common condition in newborns, characterized by a yellowing of the skin and eyes, usually due to an immature liver. It's not specifically linked to maternal rubella exposure.
Choice C rationale
Transient strabismus, or temporary misalignment of the eyes, can occur in newborns but is unrelated to rubella. It usually resolves on its own as the newborn's muscles develop.
Choice D rationale
Deafness is a significant risk associated with congenital rubella syndrome. Rubella can damage the developing auditory system in utero, leading to permanent hearing loss in the newborn.
Correct Answer is A
Explanation
Choice A rationale
Penicillin is the recommended prophylactic treatment for a client at 38 weeks of gestation with a positive group B streptococcus B-hemolytic screening. It is highly effective in preventing the transmission of group B strep from mother to baby during labor and delivery. Administering Penicillin reduces the risk of neonatal sepsis, pneumonia, and meningitis caused by group B strep.
Choice B rationale
Cefazolin is an alternative antibiotic for clients allergic to penicillin. It is less preferred compared to penicillin due to its broader spectrum of activity and potential for resistance. Cefazolin can be used if the client has a non-severe penicillin allergy.
Choice C rationale
Erythromycin is not recommended for group B strep prophylaxis during labor due to its lower efficacy compared to penicillin and cefazolin. It is less effective in preventing neonatal group B strep infections and is used less frequently.
Choice D rationale
Vancomycin is used for clients with a severe penicillin allergy or for those with resistant strains of group B strep. It is a last-resort antibiotic due to its potent effect and potential side effects. It is only used when absolutely necessary.