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 D
Explanation
Choice A rationale
A respiratory rate of 34/min is within the normal range for a newborn, which is typically between 30 to 60 breaths per minute. This does not indicate immediate distress.
Choice B rationale
Acrocyanosis, or bluish discoloration of the hands and feet, is common in newborns and usually resolves within the first few days of life. It is not a sign of critical illness.
Choice C rationale
Caput succedaneum, a swelling of the soft tissues of the newborn's scalp, is a common and benign condition that resolves on its own within a few days. It does not require immediate medical attention.
Choice D rationale
An axillary temperature of 36°C (96.8°F) is considered low and may indicate hypothermia in a newborn. Hypothermia can lead to serious complications, so this newborn requires immediate assessment and intervention to stabilize their body temperature.
Correct Answer is C
Explanation
Choice A rationale
Gaining 2 pounds per week throughout the rest of pregnancy is excessive and not recommended. Normal weight gain is approximately 1 pound per week in the second and third trimesters.
Choice B rationale
Dieting during pregnancy can lead to inadequate nutrient intake for both the mother and the developing fetus. It is essential to focus on a balanced diet rather than trying to lose weight.
Choice C rationale
Meeting with a dietitian can help the client assess their nutritional needs and develop a healthy eating plan to support their pregnancy, ensuring both maternal and fetal health.
Choice D rationale
Eating an additional 700 calories per day is too high. Generally, an additional 300-500 calories per day is recommended during the second and third trimesters to support pregnancy.