A nurse is caring for a client who is in labor and tested positive for group B streptococcus B- hemolytic. Which of the following actions should the nurse take?
Reinforce to the client that they should not breastfeed after delivery.
Maintain contact precautions for the client.
Obtain a pharyngeal culture from the client.
Reinforce to the client that they will receive IV antibiotic prophylaxis.
The Correct Answer is D
Choice A reason:
The nurse should not reinforce to the client that they should not breastfeed after delivery. Group B streptococcus (GBS) is not transmitted through breast milk. It is crucial for infants born to GBS-positive mothers to receive appropriate prophylaxis, but breastfeeding is not contraindicated.
Choice B reason:
The nurse should maintain contact precautions for the client. Group B streptococcus is a highly contagious bacterium, and taking precautions can help prevent its transmission to other patients and healthcare workers.
Choice C reason:
The nurse does not need to obtain a pharyngeal culture from the client. Group B streptococcus colonization typically occurs in the genital and gastrointestinal tracts, not in the pharynx. Therefore, a pharyngeal culture would not be relevant in this situation.
Choice D reason:
This is the correct action the nurse should take. The client tested positive for group B streptococcus, which puts the newborn at risk of infection during labor and delivery. The standard protocol is to administer intravenous antibiotic prophylaxis to the mother during labor to reduce the risk of transmission to the baby.
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Related Questions
Correct Answer is B
Explanation
Choice A reason:
The nurse should not recommend drinking warm tea before bed for a pregnant client. Certain herbal teas might not be safe during pregnancy, and caffeine-containing teas should be limited due to their potential effects on the fetus. Therefore, it is best to avoid suggesting this option to the client.
Choice B reason:
This is the correct choice as relaxation exercises can be beneficial for pregnant clients who are experiencing difficulty sleeping. These exercises can help reduce stress, promote relaxation, and improve sleep quality without any adverse effects on the client or the baby.
Choice C reason:
The nurse should avoid recommending that the client sleep on their right side. While the left side is generally recommended during pregnancy to improve blood flow to the placenta and baby, sleeping on the right side is not harmful either. However, it is better to provide the most suitable option for promoting sleep, which is relaxation exercises as mentioned in Choice B.
Choice D reason:
Soaking in a hot tub for 60 minutes is not advisable during pregnancy. Prolonged exposure to high temperatures, such as in hot tubs or saunas, can raise the body's core temperature, potentially causing harm to the developing fetus. Pregnant individuals should avoid hot tubs to prevent overheating.
Correct Answer is B
Explanation
Choice A reason:
Experiences separation anxiety - This is a common behavior seen in toddlers during hospitalization. Being away from their parents or caregivers and being in an unfamiliar environment can lead to feelings of anxiety and distress. Separation anxiety is a natural response for young children who rely on their primary caregivers for comfort and security.
Choice B reason:
Fears a loss of control - Toddlers may feel overwhelmed and fearful when they find themselves in a hospital setting. The loss of control over their daily routines and environment can be frightening for them. They may be unable to understand the reasons behind medical procedures or interventions, further increasing their anxiety.
Choice C reason:
Feels hospitalization is punishment - While some children might have difficulty understanding the reasons for hospitalization, it is less common for them to perceive it as punishment.
Children at this age often lack the cognitive capacity to associate their illness with punishment.
Choice D reason:
Develops body image disturbance - Body image disturbance is not a typical behavior observed in toddlers during hospitalization. This issue is more common in older children or adolescents who may experience changes in their appearance due to medical conditions or treatments.
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