A nurse is caring for a client who is at 37 weeks of gestation and is being tested for group B streptococcus B-hemolytic (GBS). The client is multigravida and multipara with no history of GBS. She asks the nurse why the test was not conducted earlier in her pregnancy. Which of the following is an appropriate response by the nurse?
"You didn't report any symptoms of GBS during your pregnancy."
"Your previous deliveries were all negative for GBS."
"There was no indication of GBS in your earlier prenatal testing."
"We need to know if you are positive for GBS at the time of delivery."
The Correct Answer is D
Explanation
Choice A Reason:
"You didn't report any symptoms of GBS during your pregnancy." This response is incorrect because GBS infection in pregnant women often does not present with noticeable symptoms. Additionally, GBS screening is not based on symptoms but rather on the presence of the bacteria in the genital or gastrointestinal tract.
Choice B Reason:
"Your previous deliveries were all negative for GBS." This response is incorrect because GBS status can change between pregnancies. A negative result in previous pregnancies does not guarantee a negative result in subsequent pregnancies. Screening closer to the delivery date is necessary to determine the current GBS status.
Choice C Reason:
"There was no indication of GBS in your earlier prenatal testing." This response is incorrect because routine prenatal testing typically does not include GBS screening unless there are specific risk factors or symptoms present. GBS screening is specifically done closer to delivery to determine colonization status at that time.
Choice D Reason:
"We need to know if you are positive for GBS at the time of delivery." This response is appropriate. Group B streptococcus (GBS) screening is typically performed around the 35th to 37th week of pregnancy because colonization status can change over time. A negative result earlier in the pregnancy does not necessarily mean that the client will remain negative at the time of delivery. Therefore, it is essential to screen closer to delivery to determine if the client is colonized with GBS and if prophylactic measures are needed to reduce the risk of transmission to the newborn during labor and delivery.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Explanation
Choice A Reason:
Covering the exposed umbilical cord with a sterile saline-saturated towel is an appropriate intervention to prevent the cord from drying out and to reduce the risk of infection. However, this is not the most immediate action that should be taken. The priority is to relieve pressure on the umbilical cord to restore blood flow to the fetus, which is more urgent than covering the cord.
Choice B Reason:
Administering oxygen can help improve maternal oxygenation, which in turn can benefit the fetus. However, in this situation, the immediate priority is to relieve the pressure on the umbilical cord to prevent fetal hypoxia. Administering oxygen is important but secondary to the mechanical relief of cord compression.
Choice C Reason:
This is the most critical and immediate action. Applying upward pressure on the presenting part (e.g., the fetal head) can relieve pressure on the umbilical cord, which is crucial to restore blood flow to the fetus and prevent fetal hypoxia and bradycardia. This action directly addresses the life-threatening situation posed by a prolapsed umbilical cord.
Choice D Reason:
Initiating IV fluids can help maintain maternal blood pressure and support fetal circulation. However, this intervention is not as immediate or directly life-saving as relieving the pressure on the umbilical cord. It can be done after the more urgent interventions are initiated.
Correct Answer is B
Explanation
Explanation
Choice A Reason:
Cleaning the site with povidone-iodine may further irritate the exposed neural tissue and is not recommended. Povidone-iodine is a strong antiseptic that can be damaging to delicate tissues.
Choice B Reason:
Administering antibiotics helps prevent infection, which is a significant concern when there is exposure of cerebrospinal fluid due to the open neural tube defect. Infection can lead to meningitis or other serious complications if not promptly treated.
Choice C Reason:
"Prepare for surgical closure after 72 hr," may also be part of the overall plan of care, but immediate administration of antibiotics takes precedence to reduce the risk of infection while the newborn awaits surgical intervention. However, the exact timing of surgical closure may vary depending on the specific clinical circumstances and recommendations from the healthcare provider
Choice D Reason:
Monitoring the rectal temperature is important for assessing the newborn's overall well-being, but it is not the most immediate priority in this situation. The focus should be on preventing infection and protecting the exposed neural tissue.
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