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.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Group B Streptococcus (GBS) colonization in a pregnant client does not typically necessitate a cesarean birth. The primary concern with GBS is the risk of vertical transmission to the neonate during vaginal birth, which can lead to severe neonatal infections like sepsis, meningitis, or pneumonia. Cesarean section is generally reserved for obstetric indications and does not eliminate the risk of GBS transmission if membranes rupture.

Choice B rationale

Intravenous antibiotic prophylaxis is the cornerstone of preventing neonatal GBS disease in colonized mothers. The recommended antibiotics, typically penicillin or ampicillin, are administered during labor once ruptured membranes or active labor commence. This intrapartum treatment significantly reduces bacterial colonization in the birth canal, thereby minimizing the neonate's exposure to the bacteria during passage.

Choice C rationale

A vaginal culture for GBS is typically performed between 36 and 37 weeks of gestation as part of routine prenatal screening. If the client has already been screened and identified as GBS positive at 36 weeks, repeating the culture during active labor is not indicated as the colonization status is already known, and the focus shifts to prophylaxis.

Choice D rationale

Metronidazole is an antibiotic primarily effective against anaerobic bacteria and certain parasites. It is not the drug of choice for Group B Streptococcus prophylaxis. Penicillin or ampicillin are the preferred antibiotics for GBS intrapartum prophylaxis due to their effectiveness against GBS and their favorable safety profile for both the mother and the fetus.

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Correct Answer is A

Explanation

Choice A rationale

Magnesium sulfate toxicity causes central nervous system depression, including respiratory depression. A respiratory rate of 12 breaths/min indicates that the respiratory depression has resolved, suggesting the calcium gluconate, a magnesium antagonist, has effectively reversed the neuromuscular blockade caused by magnesium. A normal respiratory rate is 12-20 breaths/min.

Choice B rationale

Absent deep tendon reflexes (DTRs) are a sign of magnesium sulfate toxicity due to its depressant effect on neuromuscular transmission. If calcium gluconate were effective, DTRs would return to normal or become less diminished, indicating resolution of magnesium's inhibitory effects on the nervous system.

Choice C rationale

Slurred speech is a neurological symptom associated with magnesium sulfate toxicity, reflecting central nervous system depression. If calcium gluconate were effective in reversing the toxicity, slurred speech would improve or resolve as the central nervous system depression diminishes.

Choice D rationale

Urine output of 22 mL/hr indicates oliguria, which can be a sign of worsening preeclampsia or kidney dysfunction, and is not an indicator of effective calcium gluconate administration for magnesium toxicity. Adequate urine output (typically >30 mL/hr) is essential for magnesium excretion and overall renal function.

A. Repeat the CST in 20 minutes. B. Administer an intravenous fluid bolus. C. Prepare the client for cesarean birth. D. Allow the labor to progress naturally.

Correct Answer is D

Explanation

Choice A rationale

A negative contraction stress test (CST) indicates that the fetus tolerates uterine contractions well, with no evidence of late decelerations, implying adequate uteroplacental function. Repeating the test in 20 minutes is unnecessary as a negative result signifies fetal well-being and is a favorable outcome.

Choice B rationale

Administering an intravenous fluid bolus is often used in situations like non-reassuring fetal heart rate patterns or to improve uteroplacental perfusion, such as during a non-reactive non-stress test or before an oxytocin challenge. A negative CST indicates a healthy fetus, so a fluid bolus is not indicated.

Choice C rationale

Preparing for a cesarean birth is indicated when there is evidence of fetal distress or a high risk of adverse outcomes, such as with a positive CST (late decelerations present). A negative CST indicates a reassuring fetal status, making a cesarean birth unnecessary based solely on these test results.

Choice D rationale

A negative CST indicates a healthy fetus with good uteroplacental reserve, suggesting that the fetus will likely tolerate the stress of labor. Therefore, allowing the labor to progress naturally is the appropriate action, as there are no indications of fetal compromise.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has preeclampsia and received a dose of calcium gluconate to treat magnesium sulfate toxicity. Which of the following findings should the nurse identify as an indication that calcium gluconate was effective?

Correct Answer is A

Explanation

A nurse is performing a contraction stress test (CST) on a client who is at 40 weeks of gestation. The results of the test indicate a negative CST. Which of the following actions should the nurse take?

Correct Answer is D

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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?