A nurse is caring for a client who is in labor and tested positive for group B streptococcus B- hemolytic. Which of the following actions should the nurse take?
Reinforce to the client that they should not breastfeed after delivery.
Maintain contact precautions for the client.
Obtain a pharyngeal culture from the client.
Reinforce to the client that they will receive IV antibiotic prophylaxis.
The Correct Answer is D
Choice A reason:
The nurse should not reinforce to the client that they should not breastfeed after delivery. Group B streptococcus (GBS) is not transmitted through breast milk. It is crucial for infants born to GBS-positive mothers to receive appropriate prophylaxis, but breastfeeding is not contraindicated.
Choice B reason:
The nurse should maintain contact precautions for the client. Group B streptococcus is a highly contagious bacterium, and taking precautions can help prevent its transmission to other patients and healthcare workers.
Choice C reason:
The nurse does not need to obtain a pharyngeal culture from the client. Group B streptococcus colonization typically occurs in the genital and gastrointestinal tracts, not in the pharynx. Therefore, a pharyngeal culture would not be relevant in this situation.
Choice D reason:
This is the correct action the nurse should take. The client tested positive for group B streptococcus, which puts the newborn at risk of infection during labor and delivery. The standard protocol is to administer intravenous antibiotic prophylaxis to the mother during labor to reduce the risk of transmission to the baby.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Experiences separation anxiety - This is a common behavior seen in toddlers during hospitalization. Being away from their parents or caregivers and being in an unfamiliar environment can lead to feelings of anxiety and distress. Separation anxiety is a natural response for young children who rely on their primary caregivers for comfort and security.
Choice B reason:
Fears a loss of control - Toddlers may feel overwhelmed and fearful when they find themselves in a hospital setting. The loss of control over their daily routines and environment can be frightening for them. They may be unable to understand the reasons behind medical procedures or interventions, further increasing their anxiety.
Choice C reason:
Feels hospitalization is punishment - While some children might have difficulty understanding the reasons for hospitalization, it is less common for them to perceive it as punishment.
Children at this age often lack the cognitive capacity to associate their illness with punishment.
Choice D reason:
Develops body image disturbance - Body image disturbance is not a typical behavior observed in toddlers during hospitalization. This issue is more common in older children or adolescents who may experience changes in their appearance due to medical conditions or treatments.
Correct Answer is A
Explanation
Abdominal distention. Choice A reason:
Abdominal distention is a common manifestation of Hirschsprung's disease in infants. This condition is characterized by the absence of ganglion cells in the distal segment of the colon, leading to a functional obstruction. The absence of ganglion cells causes the affected part of the colon to become narrow and unable to relax, resulting in a buildup of stool and gas, leading to abdominal distention.
Choice B reason:
Steatorrhea, which is the presence of fatty, bulky, and foul-smelling stools, is not typically associated with Hirschsprung's disease. This manifestation is more commonly seen in conditions affecting the pancreas, liver, or small intestine, where the digestion and absorption of fats are impaired.
Choice C reason:
Blood-tinged emesis (vomiting) is not a typical manifestation of Hirschsprung's disease. This symptom is more commonly associated with gastrointestinal bleeding, which can be caused by various factors such as ulcers, esophageal varices, or gastritis.
Choice D reason:
Dysphagia, which refers to difficulty swallowing, is also not a characteristic manifestation of Hirschsprung's disease. Dysphagia is more commonly seen in conditions affecting the esophagus or throat, such as esophageal strictures or neurological disorders affecting swallowing reflexes.
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