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.

Answer and Explanation

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

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Free Nursing Study Resources

Correct Answer is B

Explanation

It is important for the nurse to clarify the client's goals for hospitalization, including the client's understanding of the role of radiation therapy in palliative care. The nurse should also assess the client's understanding of the potential benefits and risks of radiation therapy and communicate this information to the healthcare provider.

A. Inspect skin for redness. B. Use a residual limb shrinker. C. Avoid range of motion exercises. D. Apply alcohol to the residual limb after bathing.

Correct Answer is ["A","B"]

Explanation

The correct answer is a. Inspect skin for redness and b. Use a residual limb shrinker.

Choice A rationale:

Inspecting the skin for redness is crucial to identify any signs of infection or pressure sores early. Redness can indicate irritation or the beginning of a pressure ulcer, which needs to be addressed promptly to prevent further complications.

Choice B rationale:

Using a residual limb shrinker helps to reduce swelling and shape the residual limb for prosthetic fitting. It also helps in managing pain and promoting healing by providing consistent compression.

Choice C rationale:

Avoiding range of motion exercises is incorrect. Range of motion exercises are essential to maintain joint flexibility and prevent contractures, which can hinder the use of a prosthetic limb.

Choice D rationale:

Applying alcohol to the residual limb after bathing is not recommended. Alcohol can dry out the skin and cause irritation, which can lead to skin breakdown and infection. Instead, the residual limb should be kept clean and moisturized with appropriate skin care products.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with cancer is admitted to the oncology unit and tells the nurse that he is in the hospital for palliative care measures. The nurse notes that the client's admission prescriptions include radiation therapy. Which action should the nurse implement?

Correct Answer is B

Explanation

The nurse is preparing a client who had a below-the-knee (BKA) amputation for discharge to home. Which recommendation(s) should the nurse provide this client? (Select all that apply.)

Correct Answer is ["A","B"]

Explanation

The nurse is evaluating a tertiary prevention program for clients with cardiovascular disease implemented in a rural health clinic. Which outcome indicates the program is effective?

The nurse is assessing a 4-year-old child with eczema. The child's skin is dry and scaly, and the mother reports that the child frequently scratches the lesions on the skin to the point of causing bleeding. Which guideline is indicated for care of this child?

While changing a client's postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

A client who is having gastrointestinal (GI) difficulties is undergoing diagnostic procedures. The client asks the nurse about the difference between ulcerative colitis and Crohn's disease. Which information should the nurse offer?

A client receives a prescription for a fluid bolus of 0.9% sodium chloride, USP 200 mL to be infused in 30 minutes. How many mL/hr should the nurse program the infusion pump to deliver? (Enter numerical value only.)