A nurse is admitting a client who is at 35 weeks of gestation and is experiencing mild vaginal bleeding due to placenta previa. Which of the following actions should the nurse plan to take?

Choice A rationale:

The nurse should plan to administer Ampicillin to the client with a group B streptococcus (GBS) B-hemolytic infection. Ampicillin is the first-line antibiotic treatment for intrapartum prophylaxis in GBS-positive pregnant women. It helps prevent the transmission of the bacteria from the mother to the newborn, reducing the risk of early-onset GBS infection in the infant.

Choice B rationale:

Azithromycin is not the appropriate choice for treating GBS B-hemolytic infection during labor. While Azithromycin is effective against certain bacteria, it is not the recommended antibiotic for GBS prophylaxis in labor. Ampicillin or Penicillin is the preferred medication in this scenario.

Choice C rationale:

Ceftriaxone is not the appropriate medication for treating GBS B-hemolytic infection during labor. Ceftriaxone belongs to the cephalosporin class of antibiotics and is not the first-line treatment for GBS prophylaxis. Ampicillin or Penicillin is the preferred choice.

Choice D rationale:

Acyclovir is an antiviral medication and is not indicated for the treatment of GBS B-hemolytic infection. GBS is a bacterial infection, and antiviral medications like Acyclovir do not have an effect on bacteria.

Choice D rationale:

During the transition phase of labor, the nurse should encourage the client to use a pant- blow breathing pattern. The transition phase is intense, and pant-blow breathing (a form of controlled breathing) can help the client manage the pain and reduce anxiety. Panting during contractions allows the client to focus on short, shallow breaths, which can be more effective than deep breathing during this stage.

Choice A rationale:

Assisting the client to void every 3 hours is important during labor, but it is not specific to the transition phase. The nurse should encourage the client to void regularly during the entire labor process to prevent bladder distension and facilitate the descent of the baby. However, during the transition phase, the client may be more focused on contractions and may not need reminders to void every 3 hours.

Choice B rationale:

Monitoring contractions every 30 minutes is not appropriate during the transition phase of labor. The transition phase is characterized by frequent and strong contractions, and continuous monitoring of contractions is usually required during this phase to ensure fetal well-being and progress in labor.

Choice C rationale:

Placing the client into a lithotomy position is not appropriate during the transition phase of labor. The lithotomy position, where the client lies on their back with legs raised and supported in stirrups, is often used during the pushing phase. During the transition phase, it is more common for the client to be in an upright or semi-reclining position to facilitate the descent of the baby through the birth canal.