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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?

 

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

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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View Related questions

Correct Answer is A

Explanation

Choice A rationale

An indwelling urinary catheter can increase the risk of falls because it may cause discomfort and restricted mobility, leading the client to move awkwardly or lose balance.

Choice B rationale

While a second-degree perineal laceration might cause pain and limited mobility, it doesn't usually contribute as significantly to fall risk as an indwelling catheter.

Choice C rationale

Saturating a perineal pad every 5 to 6 hours may indicate heavy postpartum bleeding, but it isn't directly related to fall risk. The concern here would be more about monitoring for hemorrhage rather than falls.

Choice D rationale

Breast engorgement causes discomfort and pain but doesn't directly affect a client's mobility or balance, making it less likely to increase fall risk.

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.

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