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 D

Explanation

Choice A reason:

Washing off the zinc oxide ointment with each diaper change would not be beneficial for the infant's diaper dermatitis. Zinc oxide ointment forms a protective barrier on the skin, and frequent washing could remove this barrier, reducing its effectiveness in promoting healing and protecting the irritated skin.

Choice B reason:

Shaking talcum powder onto the reddened areas is not a suitable approach. Talcum powder can further irritate the skin and worsen the diaper dermatitis. It is best to avoid using talcum powder on an infant's delicate skin.

Choice C reason:

Using a hair dryer, even on the lowest setting, to dry the diaper area is not recommended. The hot air from the hair dryer can be too harsh for the infant's sensitive skin and might exacerbate the irritation. It is safer to let the diaper area air dry naturally or pat it gently with a soft cloth.

Choice D reason:

This is the correct choice. Using moist disposable wipes that are detergent-free is a suitable option for cleaning the infant's diaper area. Detergent-free wipes are gentle on the skin and less likely to cause further irritation. Additionally, keeping the area clean and dry is essential for managing diaper dermatitis, and these wipes can help achieve that without causing harm.

A. Experiences separation anxiety. B. Fears a loss of control. C. Feels hospitalization is punishment. D. Develops body image disturbance.

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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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

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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