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.

Answer and Explanation

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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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.

A. Provide the client with a carbonated beverage. B. Encourage the client to lie on their right side. C. Encourage the client to ambulate. D. Provide the client with straws for beverages.

Correct Answer is A

Explanation

Choice A reason:

The nurse should provide the client with a carbonated beverage as a nonpharmacologic intervention to reduce pain from intestinal gas. Carbonated beverages, like soda or sparkling water, can help alleviate gas by promoting burping, which releases trapped gas from the digestive system. The effervescence of the carbonated drink can help relieve the discomfort caused by accumulated gas, offering relief to the client.

Choice B reason:

Encouraging the client to lie on their right side is not an effective nonpharmacologic intervention for reducing pain from intestinal gas. Although positioning can sometimes aid in relieving discomfort, lying on the right side does not specifically target the reduction of gas. Therefore, it is not the most appropriate choice in this scenario.

Choice C reason:

Encouraging the client to ambulate is a beneficial nonpharmacologic intervention for various post-operative conditions. However, when it comes to reducing pain from intestinal gas, it may not be as effective as other options. While movement can aid in gas passage through the digestive system, it might not be the most immediate or direct solution for alleviating the client's discomfort.

Choice D reason:

Providing the client with straws for beverages does not directly address the issue of intestinal gas. It is an unrelated intervention and may not provide any significant relief for the client's discomfort.

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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?

Nursing Test Bank

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