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A nurse is caring for a female client who is at 12 weeks of gestation in the prenatal clinic.

Exhibits
A nurse in a prenatal clinic is reviewing the laboratory results for a client who is at 12 weeks of gestation. Which of the following actions should the nurse take?

A.

Administer ceftriaxone IM.

B.

Obtain a blood culture.

C.

Administer rubella vaccine.

D.

Obtain a maternal serum alpha-fetoprotein specimen.

Answer and Explanation

The Correct Answer is A

Choice A rationale: Ceftriaxone IM is the recommended treatment for Neisseria gonorrhoeae infection during pregnancy. Untreated gonorrhea increases the risk of chorioamnionitis, preterm labor, premature rupture of membranes, and neonatal complications such as ophthalmia neonatorum. Ceftriaxone is safe in pregnancy and effective against gonorrhea. Prompt treatment prevents maternal complications and vertical transmission to the neonate. Therefore, administration of ceftriaxone IM is the correct nursing action in this case.

Choice B rationale: A blood culture is not indicated for a localized gonorrhea infection. Blood cultures are obtained when systemic infection or sepsis is suspected, which is not the case here. The client is asymptomatic aside from the positive culture result, with no fever, chills, or systemic signs of bacteremia. Therefore, obtaining a blood culture would not be an appropriate or necessary intervention in this scenario.

Choice C rationale: The rubella vaccine is a live attenuated vaccine and is contraindicated during pregnancy because of the potential teratogenic effects on the fetus. Women who are non-immune to rubella, as indicated by a titer less than 1:8, should be vaccinated postpartum before discharge to prevent infection in future pregnancies. Administering the vaccine during pregnancy is unsafe and therefore not an appropriate action at this time.

Choice D rationale: Maternal serum alpha-fetoprotein (MSAFP) screening is typically performed between 15 and 20 weeks of gestation to assess for neural tube defects and chromosomal abnormalities. At 12 weeks, it is too early to obtain this specimen, and the result would not be reliable. Therefore, ordering MSAFP at this gestational age is inappropriate. The correct timing should be discussed and scheduled for later in the pregnancy.


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Related Questions

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"C"},"C":{"answers":"C"},"D":{"answers":"A"},"E":{"answers":"C"},"F":{"answers":"B"}}

Explanation

🧾 Explanation

  1. Moderate lochia rubra
    • Normal up to 1–2 weeks postpartum. Not related to mastitis.
  2. Temperature 38.4°C
    • Still febrile after 24 hrs of antibiotics → infection not yet controlled.
  3. Purulent nipple discharge
    • New finding. Indicates possible breast abscess or worsening mastitis.
  4. Hemoglobin 12 g/dL
    • Stable and within normal range. Not relevant to mastitis progression.
  5. WBC 35,000/mm³
    • Increased from 28,000 → worsening systemic inflammatory response.
  6. Decreased pain
    • Symptomatically better, but this may reflect partial relief from antibiotics/analgesics rather than full resolution. Still, it’s a positive sign.

Summary:

  • Improving: Pain relief.
  • Unrelated: Lochia rubra, hemoglobin.
  • Worsening: Persistent fever, purulent nipple discharge, rising WBC.

This mixed picture suggests partial response but possible complication (breast abscess). The nurse should notify the provider promptly, anticipate breast ultrasound to rule out abscess, and continue close monitoring.

Correct Answer is D

Explanation

Choice A rationale

A fetal heart rate (FHR) of 150/min with moderate variability is within the normal range (110-160/min) and suggests adequate fetal oxygenation, which is less indicative of a significant Grade 2 abruption. A Grade 2 (moderate) abruption typically involves 20%-50% placental separation, often resulting in fetal distress like persistent late decelerations or tachycardia as a compensatory response to hypoxemia.

Choice B rationale

Placenta previa, not abruption, classically presents with painless, bright red vaginal bleeding due to the placenta covering the cervical os. Placental abruption, caused by premature separation of the placenta from the uterine wall, typically causes bleeding accompanied by significant, severe, and unrelenting abdominal pain due to concealed hemorrhage and uterine irritability.

Choice C rationale

A soft abdomen suggests a relaxed uterus, which is normal. In Grade 2 placental abruption, blood often becomes trapped between the placenta and uterine wall, causing uterine tetany or hypertonicity (increased muscle tone) and rigidity, which presents as a firm or board-like abdomen that is tender to palpation.

Choice D rationale

A heart rate of 120/min (tachycardia) in the client is an expected finding in a moderate (Grade 2) placental abruption. The client is experiencing hypovolemia due to hemorrhage (internal and/or external bleeding), which triggers a compensatory sympathetic nervous system response, increasing the heart rate to maintain cardiac output and tissue perfusion.

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