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 D
Explanation
Choice A reason:
The nurse should inform the adolescent of their right to refuse treatment because respecting the patient's autonomy and right to make their own decisions about their healthcare is essential. This is especially true for an adolescent who is living on their own, as they have the legal capacity to make their medical decisions independently.
Choice B reason:
This statement is incorrect because, in most jurisdictions, adolescents who live on their own are considered emancipated minors, meaning they have the legal right to make their medical decisions without involving a parent or guardian. Requiring a parent or guardian's consent would not be applicable in this situation.
Choice C reason:
This statement is incorrect and irrelevant to the situation. Marriage status does not determine an individual's ability to make their own health care decisions. Regardless of marital status, an adolescent living on their own has the right to make their medical choices.
Choice D reason:
This is the correct choice. The nurse should emphasize the adolescent's right to refuse treatment if they wish to do so. It is crucial to respect their autonomy and ensure that they are fully informed about the potential consequences of their decision. However, the nurse should also provide relevant information about the treatment's benefits and risks to help the patient make an informed decision.
Correct Answer is B
Explanation
Choice A reason: Following the rupture of membranes, delivery is imminent and administration of glucocorticoids may not take effect to benefit the baby.
Choice B reason:
Monitoring the client's temperature (Choice B) is important as the client is at risk of chorioamnionitis which may increase the risk of severe early neonatal sepsis. Changes in temperature as they may warrant anibiotic therapy and immediate delivery.
Choice C reason:
Giving calcium gluconate (Choice C) is not indicated in this situation. Calcium gluconate is typically administered in cases of magnesium sulfate toxicity or to treat hypocalcemia, neither of which is mentioned in the scenario. Therefore, it is not the appropriate action for the nurse to take at this time.
Choice D reason:
Preparing the client for an amniocentesis (Choice D) is not the correct action in this situation. An amniocentesis is a procedure in which a small amount of amniotic fluid is withdrawn for various diagnostic reasons, such as genetic testing or assessing fetal lung maturity. However, in this scenario, the priority is to administer glucocorticoids to promote fetal lung maturity, and an amniocentesis does not address this immediate concern.
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