A primiparous woman presents in labor with the following labs: hemoglobin 10.9 g/dL (109 g/L), hematocrit 29% (0.29), hepatitis surface antigen positive, group B Streptococcus positive, and rubella non- immune.
Which intervention should the nurse implement?
Reference Range
- Hemaglobin [Reference Range:12-16 g/dL (120-160 g/L)]
- Hematrocrit [Reference Range:Pregnant female: 37% to 47% (0.37 to 0.47 volume fraction)] Hepatitis Surface Antigen [Reference Range: negative]
- Group B Streptococcus [Reference Range: negative]
Transfuse two units packed red blood cells.
Administer ampicillin 2 grams intravenously.
Inject hepatitis B immune globulin 0.5 mL.
Give measles, mumps, rubella vaccine 0.5 mL.
The Correct Answer is B
The client's labs indicate that she has a positive result for group B Streptococcus (GBS) and hepatitis surface antigen, and she is also identified as rubella non-immune.
Ampicillin is the recommended antibiotic for intrapartum prophylaxis against GBS infection to reduce the risk of transmission to the newborn. Administering ampicillin intravenously would help protect the newborn from potential GBS-related complications. Transfusion of packed red blood cells is not indicated based on the hemoglobin and hematocrit values provided. The client's hemoglobin and hematocrit levels, although lower than the reference range, are not critically low and do not necessarily require a blood transfusion.
Injecting hepatitis B immune globulin is not the appropriate intervention in this case. The client is positive for hepatitis surface antigen, indicating active infection, and requires appropriate medical management, which may include antiviral treatment.
Administering the measles, mumps, rubella vaccine is contraindicated during pregnancy. Vaccination for rubella is typically recommended prior to conception or postpartum to prevent congenital rubella syndrome.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) Incorrect - Developing new screening protocols is important, but it doesn't directly indicate that the program has prevented diseases. Screening protocols might catch diseases but don't prevent them.
B) Incorrect - Clients receiving rehabilitation indicates they already had disease complications, which is not a primary prevention outcome.
C) Correct- An improvement in average client scores on risk factor knowledge tests suggests that the primary prevention program has successfully educated clients about behaviors and practices that can help prevent sexually transmitted diseases. This improvement indicates that clients have a better understanding of the risks and protective measures, which is a key indicator of program effectiveness.
D) Incorrect - Diagnosing clients early in their disease process is related to early detection (secondary prevention), not primary prevention.
Correct Answer is ["A","B","C","D","E"]
Explanation
It is important to assess the child's vital signs, including oxygen saturation (SaO2), to ensure their stability and identify any signs of respiratory distress or other abnormalities that may impact medication administration.
Prior to administering any medication, it is crucial to verify if the child has any known allergies to medications. This information is essential for ensuring the safety of the child and preventing any potential allergic reactions.
Before administering pain medication, the nurse must verify that the prescribed dosage is appropriate for the child's age, weight, and condition. Ensuring the correct dosage helps prevent medication errors and potential adverse effects.
It is important to use a validated pain assessment tool that is appropriate for the child's age and cognitive abilities. This allows for a comprehensive and accurate assessment of the child's pain level, helping guide appropriate pain management interventions.
Considering the child has cognitive and speech delays, the input from the parent regarding the child's pain is valuable. The nurse should assess and consider the parent's report of the child's pain in conjunction with other assessment findings to ensure effective pain management.
Subjective pain assessment is mentioned as a finding but may not require immediate action, as it needs to be combined with other assessment data for a comprehensive evaluation.
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