A nurse is admitting a client who is at 39 weeks of gestation and in active labor. The client reports being positive for group B streptococcus (GBS) when screened at 36 weeks of gestation. Which of the following actions should the nurse expect to 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
Cesarean birth is not necessarily required for GBS-positive clients as long as IV antibiotic prophylaxis is administered during labor to prevent transmission to the newborn.
Choice B rationale
IV antibiotic prophylaxis, typically with penicillin or ampicillin, is given to GBS-positive clients during labor to prevent neonatal GBS infection.
Choice C rationale
Obtaining a vaginal culture at 39 weeks of gestation is not necessary if the client was already screened and found positive for GBS at 36 weeks.
Choice D rationale
Metronidazole is used to treat bacterial vaginosis or trichomoniasis, not GBS infection; thus, it is not appropriate for this scenario. .
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Correct Answer is B
Explanation
Choice A rationale
Informing the client to expect dark-colored stools is inaccurate for methotrexate administration. Dark stools typically indicate gastrointestinal bleeding, not a side effect of methotrexate.
Choice B rationale
Wearing two pairs of gloves is necessary when handling methotrexate as it is a cytotoxic drug. This protects healthcare workers from accidental exposure to the medication, which can be harmful.
Choice C rationale
Methotrexate is typically administered intramuscularly or orally, not subcutaneously. Administering it subcutaneously is incorrect and would not be effective for treating an ectopic pregnancy.
Choice D rationale
While it is essential to counsel the client on safe intercourse practices, instructing to use a condom for only 7 days post-administration is not specific or relevant to the methotrexate therapy for ectopic pregnancy.
Correct Answer is D
Explanation
Choice A rationale
Wound infection usually presents with redness, warmth, and swelling, not just yellow exudate. The presence of yellow exudate alone typically does not indicate an infection.
Choice B rationale
Ulceration would involve the breakdown of skin or tissue, which is not indicated by the presence of yellow exudate. Ulcerations are more severe and painful than normal post-
circumcision healing.
Choice C rationale
Exposure to urine can cause irritation but does not typically result in yellow exudate. Proper diapering and cleaning prevent this irritation, and exudate is part of the healing process,
not a result of urine exposure.
Choice D rationale
Healing is indicated by the presence of yellow exudate, which is a normal part of the healing process post-circumcision. It signifies that the glans is recovering as expected. .