Nokea
The labor and delivery nurse reviews a client’s prenatal records and notes that the client had a positive GBS culture at 27 weeks gestation. Based on current guidelines, what is the recommended plan?
- A. Send a GBS to the laboratory immediately
- B. Prepare to administer penicillin prophylactically
- C. Determine if a follow-up culture was done at 38 weeks gestation
- D. Determine if the patient received antibiotics for the positive strep
Correct Answer: B
Rationale: The correct answer is B: Prepare to administer penicillin prophylactically. This is the recommended plan because current guidelines suggest administering intrapartum prophylaxis with penicillin for GBS-positive pregnant women to prevent neonatal GBS disease. Choice A is incorrect because sending a GBS to the laboratory immediately is unnecessary since the previous positive culture result is already known. Choice C is incorrect because follow-up cultures are not routinely recommended at 38 weeks gestation. Choice D is incorrect because determining if the patient received antibiotics for the positive strep does not address the need for intrapartum prophylaxis specifically with penicillin.
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During an assessment of a client at 32 weeks gestation with a history of congenital ventral septal defect, a nurse notes that the client is experiencing a nonproductive cough on minimal exertion. The nurse knows that this assessment finding may indicate which of the following?
- A. Orthopnea
- B. Pulmonary edema
- C. Anemia
- D. Decreased blood volume
Correct Answer: B
Rationale: The correct answer is B: Pulmonary edema. A nonproductive cough on minimal exertion in a pregnant client with a history of congenital ventral septal defect suggests pulmonary edema. This is due to fluid accumulation in the lungs, leading to coughing. Pulmonary edema can occur due to increased blood volume and pressure on the heart during pregnancy, exacerbating the client's pre-existing heart condition. Orthopnea (choice A) is difficulty breathing while lying flat, not specifically related to coughing. Anemia (choice C) may cause fatigue and weakness but is not directly linked to a nonproductive cough. Decreased blood volume (choice D) is unlikely in a pregnant client and would not explain the cough.
The nurse is caring for a woman with a history of a previous preterm birth. Based on current knowledge related to cervical incompetency, which should the nurse do?
- A. Prepare the woman for an abdominal ultrasound
- B. Place the patient on her left side to increase perfusion to the fetus
- C. Be prepared to discuss the action and side effects of progesterone
- D. Monitor the patient’s blood pressure closely
Correct Answer: C
Rationale: The correct answer is C because progesterone is recommended for women with a history of preterm birth due to cervical incompetency. Progesterone helps to reduce the risk of another preterm birth by supporting the cervix and preventing it from opening too early. It is important for the nurse to discuss the action and side effects of progesterone with the patient to ensure informed decision-making.
Choice A is incorrect as an abdominal ultrasound is not directly related to managing cervical incompetency. Choice B is incorrect as positioning the patient on her left side does not address the issue of cervical incompetency. Choice D is also incorrect as monitoring blood pressure is not the primary intervention for managing cervical incompetency in this case.
A nurse is caring for a client who is G1P0 and 36 weeks gestation who has been diagnosed with severe pre-eclampsia. Her blood pressure is 165/110. The physician has ordered hydralazine. The nurse knows she should do which of the following when administering this medication?
- A. Position the client supine with the head of the bed elevated 30 degrees.
- B. Get baseline blood pressure and pulse and monitor frequently during administration.
- C. Administer medication every 5 minutes until blood pressure is stabilized.
- D. Inform the client that this may cause a positive direct Coombs test result.
Correct Answer: B
Rationale: The correct answer is B. The nurse should get baseline blood pressure and pulse and monitor frequently during administration to assess the effectiveness and safety of the medication. This is crucial in managing severe pre-eclampsia.
Choice A is incorrect because the client should be positioned on her left side to prevent vena cava compression, not supine with the head of the bed elevated.
Choice C is incorrect because administering medication every 5 minutes without proper monitoring can lead to adverse effects like hypotension.
Choice D is incorrect because hydralazine does not cause a positive direct Coombs test result. It is important for the nurse to provide accurate information to the client.
The nurse is caring for a client in labor who is HIV positive. Which nursing care should be included?
- A. Administering antiretroviral drugs as ordered
- B. Assisting the woman on a labor ball to help with natural descent of the fetus
- C. Handling the newborn with gloves until it receives its first bath
- D. Encouraging the mother to breastfeed soon after delivery
Correct Answer: A
Rationale: The correct answer is A because administering antiretroviral drugs as ordered helps reduce the risk of vertical transmission of HIV from mother to baby during childbirth. This treatment is essential in managing the client's HIV status and ensuring the safety of the newborn.
Choice B is incorrect because using a labor ball does not directly address the HIV status of the client or the transmission risk to the newborn.
Choice C is incorrect as wearing gloves when handling the newborn does not replace the need for antiretroviral therapy to prevent transmission.
Choice D is incorrect because breastfeeding can transmit HIV from mother to baby, so it is not recommended for HIV-positive mothers to breastfeed.
The nurse is caring for a woman who is suspected of having chorioamnionitis. Which of the following are risk factors for chorioamnionitis? Select all that apply.
- A. Changing cat litter
- B. Frequent vaginal examination during labor
- C. Gestational diabetes
- D. Preterm premature rupture of the membranes
Correct Answer: A
Rationale: The correct answer is A: Changing cat litter. Chorioamnionitis is an infection of the amniotic fluid and membranes. Changing cat litter exposes the woman to toxoplasmosis, a risk factor for chorioamnionitis. Choices B, C, and D are incorrect. Vaginal exams during labor can introduce bacteria but are not a direct risk factor. Gestational diabetes is unrelated, and preterm premature rupture of membranes can increase infection risk but is not a direct cause like exposure to toxoplasmosis.