A patient with a history of mitral valve prolapse is admitted at 41 weeks gestation for induction of labor.The doctor prescribes intravenous antibiotic therapy for the patient to be given during labor.Based on this information, what is the primary reason for administering antibiotics to this patient at this time?

This is because the first priority for a pregnant woman with acute abdominal pain is to assess the fetal well-being and rule out any obstetric complications such as placental abruption, uterine rupture, or preterm labor.Fetal heart tones can indicate the presence and viability of the fetus and alert the nurse to any signs of fetal distress or hypoxia.

Choice A: Obtain a full history is wrong because it is not the most urgent action.

A full history can provide valuable information about the possible causes of abdominal pain, but it should not delay the assessment of fetal status and maternal vital signs.

Choice B: Examine the cervix for dilation is wrong because it can be harmful in some cases.A digital cervical examination should be avoided until placenta previa is ruled out by ultrasound, as it can cause bleeding and worsen the condition.

Moreover, cervical dilation alone does not indicate the cause or severity of abdominal pain.

Choice D: Palpate for uterine contraction frequency is wrong because it is not the most reliable method to assess labor.Uterine contractions can be measured by external tocodynamometry or internal intrauterine pressure catheter, which can provide more accurate and objective data than manual palpation.

Furthermore, uterine contractions do not necessarily indicate labor, as they can also be caused by other conditions such as dehydration, infection, or irritable uterus.

The correct answer is choice A. Maintaining the infants’ airways is the nurse’s priority when caring for a set of twins delivered by cesarean delivery.This is because twins are more likely to be born early and need special care after birth than single babies.They may have breathing difficulties or low oxygen levels and require oxygen therapy or ventilation.

The nurse should assess the infants’ respiratory status and intervene as needed.

Choice B is wrong because keeping the infants in a warm, draft-free environment is important but not as urgent as ensuring their airways are clear and they are breathing well.Premature twins may have trouble regulating their body temperature and need to be kept warm, but this can be done after their airways are secured.

Choice C is wrong because placing identification bands on the infants is a standard procedure but not a priority.

The nurse should make sure the infants are correctly identified and matched with their mother, but this can be done after their vital signs are stable.

Choice D is wrong because monitoring the infants’ vital signs is also important but not as urgent as maintaining their airways.

The nurse should check the infants’ heart rate, blood pressure, temperature and blood sugar levels regularly, but this can be done after their respiratory status is assessed and managed.

Normal ranges for vital signs in newborns are:

• Heart rate: 100 to 160 beats per minute

• Blood pressure: 50 to 75 mm Hg systolic and 30 to 45 mm Hg diastolic

• Temperature: 36.5 to 37.5°C (97.7 to 99.5°F)

• Blood sugar: 40 to 80 mg/dL