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?

Explanation

Choice A Reason:

"When was the last time you ate meat?" This question is not relevant for a client who adheres to a vegan diet, as they abstain from consuming meat or animal products.

Choice B Reason:

"How much protein do you eat in a day?" Assessing the client's protein intake is essential because protein is a critical component of a healthy diet, especially during pregnancy. Since the client adheres to a vegan diet, obtaining an understanding of their protein intake is particularly important, as plant-based protein sources may require more careful planning to ensure adequate intake. Adequate protein intake is vital for supporting maternal tissue growth, blood volume expansion, and fetal development.

Choice C Reason:

"Are you taking a Vitamin C supplement?" While vitamin C is important, especially for individuals following a vegan diet to aid in the absorption of non-heme iron from plant-based sources, it may not be the primary concern when assessing overall dietary intake. Additionally, vitamin C supplementation may not be necessary if the client consumes a varied diet rich in fruits and vegetables.

Choice D Reason:

"Have you considered eating shellfish?" This question is not appropriate for a client who adheres to a vegan diet, as shellfish are animal products and are not consumed in a vegan diet. Instead, the focus should be on assessing the client's intake of plant-based protein sources.

Explanation

Choice A Reason:

Vigorously massaging the injection site is not recommended as it may increase discomfort or bruising at the injection site. Gentle pressure may be applied if necessary, but vigorous massage is not necessary.

Choice B Reason:

Inserting the needle at a 45° angle for injection is incorrect. When administering intramuscular injections to newborns, the needle is typically inserted at a 90° angle (perpendicular to the skin) to ensure proper delivery of the vaccine into the muscle. A 45° angle is more commonly used for subcutaneous injections.

Choice C Reason;

Using a 21-gauge needle for the injection is incorrect. The gauge of the needle refers to its thickness. While the gauge of the needle used for intramuscular injections can vary depending on the specific vaccine and patient factors, a 21-gauge needle may be too large for a newborn. Smaller gauge needles, such as 23-25 gauge, are typically used for newborns to minimize discomfort.

Choice D Reason:

Administering the injection into the vastus lateralis muscle is correct. When administering a hepatitis B vaccine to a newborn, it is typically given intramuscularly. The vastus lateralis muscle, located in the thigh, is one of the recommended sites for intramuscular injections in infants. It is important to choose an appropriate muscle for injection to ensure proper absorption of the vaccine.