A client who is positive for Neisseria gonorrhoeae vaginally delivered a newborn.Which medication should the nurse administer to the newborn?

Latanoprost eye drops.

Erythromycin ointment.

Tetracaine eye drops.

Neomycin ointment.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Latanoprost eye drops are used to reduce intraocular pressure in glaucoma patients and are not relevant for a newborn exposed to Neisseria gonorrhoeae.

Choice B rationale

Erythromycin ointment is the correct medication to administer to a newborn exposed to Neisseria gonorrhoeae. It is used to prevent ophthalmia neonatorum, an eye infection caused by the bacteria. Administering erythromycin ointment is essential to protect the newborn's eyes from potential blindness or severe infection.

Choice C rationale

Tetracaine eye drops are a topical anesthetic used to numb the eyes during procedures and are not indicated for preventing neonatal eye infections caused by Neisseria gonorrhoeae.

Choice D rationale

Neomycin ointment is an antibiotic used for treating bacterial infections, but it is not the standard treatment for preventing ophthalmia neonatorum in newborns exposed to Neisseria gonorrhoeae. Erythromycin ointment is the recommended prophylactic treatment. .

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Correct Answer is ["A","C","F"]

Explanation

Choice A rationale

Gravida 4 para 3 indicates a history of multiple pregnancies and deliveries, which can increase the risk of uterine atony, postpartum hemorrhage, and placental issues. This client’s obstetric history makes her high-risk due to potential complications associated with multiparity.

Choice B rationale

A fetal heart rate of 136 to 142 beats/minute is within the normal range for a fetus, indicating good fetal well-being. This data point does not place the client at increased risk.

Choice C rationale

Variable decelerations to 120 beats/minute lasting 20 seconds suggest umbilical cord compression, which can lead to fetal hypoxia if persistent and untreated. Variable decelerations are an indicator of potential fetal distress, making this a significant risk factor.

Choice D rationale

A gestation of 37-weeks, 1-day is considered term, and while there may be some risks associated with early-term delivery, this data point alone does not significantly increase risk in a low-risk pregnancy.

Choice E rationale

A pain rating of 5 on a 0 to 10 pain scale with each contraction is indicative of moderate pain, which is expected during labor. Pain severity alone does not increase the client's risk for complications.

Choice F rationale

A vaginal exam showing 4 cm dilation, 50% effacement, and -3 station indicates early labor. However, the -3 station suggests that the fetus is still high in the pelvis, which can be a concern if there is prolonged labor or failure to progress.

Choice G rationale

Contractions every 3 to 4 minutes, moderate to palpation, are consistent with active labor and are not indicative of an increased risk for complications in this context.

Choice H rationale

An A-blood type and receiving Rh(D) immune globulin address Rh incompatibility and prevention of hemolytic disease in the newborn. This data point does not place the client at increased risk.

A. Increase IV fluids. B. Obtain blood pressure. C. Stop infusion of magnesium. D. Administer oxygen. E. Obtain serum magnesium level. F. Prepare for a cesarean delivery. G. Administer calcium gluconate. H. Prepare to prevent respiratory or cardiac arrest.

Correct Answer is ["A","C","D","E","G"]

Explanation

Choice A rationale

Increasing IV fluids is a critical intervention to maintain maternal hemodynamic stability and prevent complications related to fluid imbalance. It helps support blood pressure and overall fluid status during labor and delivery.

Choice B rationale

While obtaining blood pressure is important for monitoring maternal status, it is not an immediate intervention compared to others listed. Blood pressure monitoring is part of routine assessment but not an emergency action.

Choice C rationale

Stopping the infusion of magnesium is essential if there are signs of magnesium toxicity or adverse effects. Magnesium can impact respiratory and cardiac function, so stopping the infusion is a priority.

Choice D rationale

Administering oxygen is an immediate intervention to ensure adequate oxygenation for both the mother and the fetus. It is crucial during labor and delivery to prevent hypoxia and related complications.

Choice E rationale

Obtaining serum magnesium level is necessary to assess for magnesium toxicity and guide further interventions. It provides important information on the mother's magnesium status and helps in making clinical decisions.

Choice F rationale

Preparing for a cesarean delivery is not an immediate intervention unless there are specific indications for surgical delivery. It should be based on clinical findings and maternal-fetal status.

Choice G rationale

Administering calcium gluconate is the antidote for magnesium toxicity and is an immediate intervention if signs of toxicity are present. It helps counteract the effects of excessive magnesium.

Choice H rationale

Preparing to prevent respiratory or cardiac arrest is a critical intervention in severe cases of magnesium toxicity, but it should be part of a broader emergency management plan rather than an immediate action. .

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A client who is positive for Neisseria gonorrhoeae vaginally delivered a newborn.Which medication should the nurse administer to the newborn?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse reviews the history and physical and nurses' notes to determine risk factors for this client.Which potential issue(s) place the client at risk? Select all that apply.

Correct Answer is ["A","C","F"]

Explanation

The nurse reviews the assessment findings along with the healthcare provider's prescriptions.Which immediate intervention(s) would the nurse initiate? Select all that apply.

Correct Answer is ["A","C","D","E","G"]

Explanation

The nurse determines the need to perform further assessment based on the client's situation.Select the 2 actions that the nurse should perform immediately.

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