A nurse is caring for a female client who is at 12 weeks of gestation in the prenatal clinic.
Administer ceftriaxone IM.
Obtain a blood culture.
Administer rubella vaccine.
Obtain a maternal serum alpha-fetoprotein specimen.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Avoiding the preschooler's presence at prenatal visits can inadvertently promote feelings of exclusion and resentment, suggesting the new sibling is an unwelcome disruption. In contrast, involving the older child in the pregnancy experience, like listening to the fetal heartbeat, helps normalize the upcoming change and prepares them for the new family dynamic, fostering a positive adjustment. This inclusion is crucial for emotional security.
Choice B rationale
Making a significant change, such as moving the preschooler from a crib to a bed, immediately before or the day the new baby arrives, associates the loss of their comfortable sleeping arrangement with the sibling's arrival. This can be viewed as a punishment, increasing stress and anxiety and potentially fueling sibling rivalry and regression. Major changes should be made several weeks before the birth.
Choice C rationale
Planning and dedicating specific, high-quality individual time ("special time") with the preschooler reassures them of their continued importance and secures their parent-child bond. This counteracts the potential feeling of being displaced or replaced by the newborn, which is critical for maintaining their self-esteem and emotional well-being during the family transition.
Choice D rationale
Insisting the initial encounter be a visual of the parent holding the baby can immediately trigger jealousy and a sense of loss of parental attention, as the parent is focused elsewhere. Instead, the parent should greet the preschooler first with open arms and allow the child to approach the baby on their own terms, promoting a gentler, more positive introduction.
Correct Answer is D
Explanation
Choice A rationale
Skin mottling, characterized by a patchy, net-like, reddish-blue discoloration of the skin, is typically caused by vasoconstriction in response to cold exposure or by circulatory changes in individuals with poor peripheral perfusion. This is not a typical, expected body change during a normal pregnancy; expected skin changes relate more to hyperpigmentation (e.g., chloasma, linea nigra).
Choice B rationale
During pregnancy, hormonal changes, particularly the increase in estrogen, shift a greater proportion of hair follicles into the anagen (growth) phase, leading to thicker, fuller hair. Hair thinning (telogen effluvium) is commonly experienced postpartum when hormone levels drop and the hair follicles shift rapidly back into the telogen (resting) phase, thus it is not expected at 14 weeks gestation.
Choice C rationale
Nipple inversion is a structural variation where the nipple is retracted into the areola; it is not a change that typically develops during pregnancy. Expected breast changes include areolar darkening (hyperpigmentation), prominent Montgomery's tubercles, and nipple erection. Nipple inversion is a pre-existing condition that may present challenges for breastfeeding.
Choice D rationale
Breast enlargement (hypertrophy) is an expected and early body change during pregnancy, beginning in the first trimester (around 6 weeks). This growth is driven by elevated estrogen and progesterone levels, stimulating the development of the mammary glands in preparation for lactation, and is often accompanied by tenderness and increased vascularity.
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