A client had a baby by normal spontaneous vaginal delivery (NSVD) 10 minutes ago.
The nurse notes that a gush of blood was just expelled and the umbilical cord lengthened. What would the nurse conclude?

Choice A rationale

Intravenous (IV) penicillin G is the first-line agent for intrapartum antimicrobial prophylaxis (IAP) to prevent early-onset Group B Streptococcus (GBS) disease in newborns. The antibiotic is administered intravenously during labor to achieve adequate drug levels in the serum and amniotic fluid, which then penetrate the fetal circulation to effectively eradicate GBS colonization and prevent vertical transmission during delivery.

Choice B rationale

Offering IV antibiotic prophylaxis to clients with unknown GBS status during labor is crucial, especially if they present with additional risk factors like fever, ruptured membranes for 18 hours or more, or labor before 37 weeks' gestation. This measure prevents GBS transmission to the newborn, as the risk outweighs waiting for culture results, thereby reducing the incidence of life-threatening neonatal sepsis or meningitis.

Choice C rationale

IAP is generally not needed for clients undergoing a scheduled cesarean section if labor has not begun and membranes are intact, as the risk of GBS transmission is low. However, if membranes have ruptured (regardless of the duration) or labor has started, the client should receive intrapartum antibiotics because the risk of vertical transmission has increased significantly.

Choice D rationale

GBS colonization is not an infection requiring treatment in the mother, thus postpartum antibiotic treatment is not indicated for GBS positive status alone. The goal of prophylaxis is to prevent transmission during labor to the neonate. Maternal treatment is only warranted if the client develops a postpartum GBS infection, such as endometritis, which is a separate clinical situation.

Choice E rationale

Administering prophylactic oral antibiotics to the neonate is not the standard of care for GBS prevention. The primary strategy is intrapartum prophylaxis to the mother. Neonates suspected of or diagnosed with GBS infection receive IV antibiotics (e.g., ampicillin and gentamicin), following a specific monitoring and treatment protocol based on their clinical condition and maternal risk factors.

Choice F rationale

The standard timing for GBS screening via rectovaginal culture is between 35 and 37 weeks and 6 days of gestation as per current guidelines. Screening later maximizes the predictive value of the test, ensuring that the colonization status at the time of delivery is accurately reflected, thus correctly identifying clients who require intrapartum antibiotic prophylaxis to protect the neonate.

Choice A rationale: Monitoring contraction duration only once every hour is inadequate and inappropriate in the presence of variable decelerations on the fetal heart rate (FHR) tracing. Variable decelerations are abrupt drops in FHR, often caused by umbilical cord compression. The nursing priority is to act immediately to relieve the compression and improve fetal oxygenation, not to observe the uterus infrequently.

Choice B rationale: Discontinuing the oxytocin infusion is the most critical and immediate intervention for this tracing. Oxytocin increases both the frequency and intensity of contractions, which can worsen cord compression and reduce the fetus’s recovery time between contractions. Stopping the uterine stimulation is the fastest way to relieve stress on the fetus.

Choice C rationale: Slowing the oxytocin infusion is a reasonable intervention, but it is not the first step. Because the variable decelerations are recurrent and pronounced, with FHR dropping below 90 bpm, the immediate and most effective action is to discontinue the infusion entirely. This should then be followed by other intrauterine resuscitation measures, such as repositioning the client laterally.

Choice D rationale: Increasing the flow rate of the main IV fluid line (a bolus) is a common intervention during fetal distress, as it can improve maternal blood volume, placental perfusion, and fetal oxygenation. However, in this case, the primary issue is recurrent variable decelerations likely caused by cord compression worsened by contractions. Therefore, the oxytocin must be stopped first to prevent further stress on the fetus.