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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Abdominal distention. Choice A reason:
Abdominal distention is a common manifestation of Hirschsprung's disease in infants. This condition is characterized by the absence of ganglion cells in the distal segment of the colon, leading to a functional obstruction. The absence of ganglion cells causes the affected part of the colon to become narrow and unable to relax, resulting in a buildup of stool and gas, leading to abdominal distention.
Choice B reason:
Steatorrhea, which is the presence of fatty, bulky, and foul-smelling stools, is not typically associated with Hirschsprung's disease. This manifestation is more commonly seen in conditions affecting the pancreas, liver, or small intestine, where the digestion and absorption of fats are impaired.
Choice C reason:
Blood-tinged emesis (vomiting) is not a typical manifestation of Hirschsprung's disease. This symptom is more commonly associated with gastrointestinal bleeding, which can be caused by various factors such as ulcers, esophageal varices, or gastritis.
Choice D reason:
Dysphagia, which refers to difficulty swallowing, is also not a characteristic manifestation of Hirschsprung's disease. Dysphagia is more commonly seen in conditions affecting the esophagus or throat, such as esophageal strictures or neurological disorders affecting swallowing reflexes.
Correct Answer is C
Explanation
Choice C reason: The correct answer is choice C, "I need to use my levalbuterol inhaler before I exercise.” This statement indicates an understanding of the teaching because using the levalbuterol inhaler before exercise is a preventive measure for asthma symptoms. Levalbuterol is a short-acting beta-agonist that helps to relax the airway muscles and improve breathing. By using it before exercise, the client can prevent exercise-induced bronchoconstriction and reduce the risk of asthma symptoms during physical activity.
Choice A reason:
The statement "I will wait 15 seconds between puffs when using my levalbuterol inhaler” is incorrect. The recommended wait time between puffs of a levalbuterol inhaler is typically 30- 60 seconds to allow the medication to be fully absorbed and work effectively. Waiting only 15 seconds might not provide the desired therapeutic effect.
Choice B reason:
The statement "I need to use my fluticasone inhaler when I start to wheeze during exercise” is incorrect. Fluticasone is a corticosteroid inhaler used for long-term control of asthma symptoms, not for immediate relief during wheezing episodes. The client should use the fluticasone inhaler daily as prescribed to prevent asthma symptoms, including wheezing, from occurring in the first place.
Choice D reason:
The statement "I will stop using my fluticasone inhaler if I experience restlessness” is incorrect. Fluticasone is a long-term controller medication, and abruptly stopping it can lead to uncontrolled asthma symptoms and potentially exacerbate the condition. Restlessness might be a side effect of the medication, but it is not a reason to discontinue its use. If the client experiences any concerning side effects, they should consult their healthcare provider for appropriate management.
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