A nurse is admitting a client who is at 9 weeks of gestation and in active labor when screened at 6 weeks of gestation.Which of the following actions should the nurse 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

Preparing for a cesarean birth is not an immediate necessity unless there are complications that warrant such intervention. Cesarean births are typically reserved for situations where vaginal delivery poses a risk to the mother or the baby.

Choice B rationale

Administering IV antibiotic prophylaxis is critical in preventing potential infections during the labor process, especially given the early gestation period. This helps in safeguarding both the mother and the fetus from infections like group B streptococcus.

Choice C rationale

Obtaining a vaginal culture is generally done to check for infections such as bacterial vaginosis or sexually transmitted infections. However, it is not an immediate priority when the patient is already in active labor.

Choice D rationale

Administering metronidazole orally is used to treat bacterial infections but is not an immediate action required in this scenario. Metronidazole may not be the most suitable choice during labor as it does not provide immediate infection prevention.

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Correct Answer is A

Explanation

Choice A rationale

An indwelling urinary catheter can increase the risk of falls because it may cause discomfort and restricted mobility, leading the client to move awkwardly or lose balance.

Choice B rationale

While a second-degree perineal laceration might cause pain and limited mobility, it doesn't usually contribute as significantly to fall risk as an indwelling catheter.

Choice C rationale

Saturating a perineal pad every 5 to 6 hours may indicate heavy postpartum bleeding, but it isn't directly related to fall risk. The concern here would be more about monitoring for hemorrhage rather than falls.

Choice D rationale

Breast engorgement causes discomfort and pain but doesn't directly affect a client's mobility or balance, making it less likely to increase fall risk.

A. I should see my provider in 2 weeks for a second dose of the immunization. B. I need to prevent getting pregnant for 4 months after I receive the immunization. C. I will need an additional rubella immunization during the first trimester of my next pregnancy. D. I can breastfeed my baby even though I received this immunization.

Correct Answer is D

Explanation

Choice A rationale

Only one dose of rubella immunization is necessary post-delivery, no need for a second dose in 2 weeks.

Choice B rationale

Prevention of pregnancy is recommended for at least 1 month (not 4 months) after receiving the rubella vaccine to avoid possible teratogenic effects.

Choice C rationale

An additional rubella immunization is not recommended during pregnancy as the live vaccine is contraindicated during gestation.

Choice D rationale

Rubella vaccine is safe for breastfeeding mothers, as it does not affect the safety of breast milk.

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A nurse is admitting a client who is at 9 weeks of gestation and in active labor when screened at 6 weeks of gestation.Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a group of clients who are postpartum.Which of the following clients is at an increased risk for a fall?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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