A nurse is discussing nonpharmacological pain management during labor with a client.
Which of the following statements by the client indicates an understanding of the teaching?

Choice A rationale: Ceftriaxone IM is the recommended treatment for Neisseria gonorrhoeae infection during pregnancy. Untreated gonorrhea increases the risk of chorioamnionitis, preterm labor, premature rupture of membranes, and neonatal complications such as ophthalmia neonatorum. Ceftriaxone is safe in pregnancy and effective against gonorrhea. Prompt treatment prevents maternal complications and vertical transmission to the neonate. Therefore, administration of ceftriaxone IM is the correct nursing action in this case.

Choice B rationale: A blood culture is not indicated for a localized gonorrhea infection. Blood cultures are obtained when systemic infection or sepsis is suspected, which is not the case here. The client is asymptomatic aside from the positive culture result, with no fever, chills, or systemic signs of bacteremia. Therefore, obtaining a blood culture would not be an appropriate or necessary intervention in this scenario.

Choice C rationale: The rubella vaccine is a live attenuated vaccine and is contraindicated during pregnancy because of the potential teratogenic effects on the fetus. Women who are non-immune to rubella, as indicated by a titer less than 1:8, should be vaccinated postpartum before discharge to prevent infection in future pregnancies. Administering the vaccine during pregnancy is unsafe and therefore not an appropriate action at this time.

Choice D rationale: Maternal serum alpha-fetoprotein (MSAFP) screening is typically performed between 15 and 20 weeks of gestation to assess for neural tube defects and chromosomal abnormalities. At 12 weeks, it is too early to obtain this specimen, and the result would not be reliable. Therefore, ordering MSAFP at this gestational age is inappropriate. The correct timing should be discussed and scheduled for later in the pregnancy.

Choice A rationale

Initiating internal fetal heart rate monitoring is an invasive procedure that is not the priority for a non-reassuring fetal heart rate pattern like late decelerations, which often indicate uteroplacental insufficiency. The first step involves non-invasive intrauterine resuscitation measures to immediately improve fetal oxygenation before considering invasive monitoring, unless the external tracing is inadequate.

Choice B rationale

Late decelerations are an indication of uteroplacental insufficiency (decreased blood flow/oxygen to the fetus during the contraction). Assisting the client to a left lateral position is the priority nursing action because it relieves pressure from the gravid uterus on the vena cava, which in turn maximizes venous return to the heart and increases blood flow and oxygen delivery to the placenta and fetus.

Choice C rationale

While uterine tachysystole (excessive frequency of contractions, greater than five in 10 minutes over 30 minutes) can cause late decelerations, palpating for it is not the absolute first action. The immediate priority is to improve fetal oxygenation by repositioning the mother. Palpation for tachysystole, however, is a quick assessment that should follow the repositioning intervention.

Choice D rationale

Increasing the infusion rate of the maintenance IV fluid (an IV fluid bolus) is a critical step in intrauterine resuscitation for late decelerations. It increases maternal blood volume, which can improve placental perfusion. However, repositioning the client is generally the most immediate, least invasive, and first step to correct or improve the blood flow to the placenta and fetus.