A nurse is planning care for a client who is scheduled for a cesarean birth.
Which of the following interventions should the nurse include in the plan of care?

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.

Choice A rationale: Calcium gluconate must be readily available whenever magnesium sulfate is administered because it serves as the antidote for magnesium toxicity. Magnesium sulfate depresses neuromuscular transmission and the central nervous system, which can lead to respiratory depression, hypotension, and cardiac arrest if serum levels become excessive. Having calcium gluconate on hand allows for immediate reversal of these life-threatening effects. This is a critical safety measure and therefore a required nursing action.

Choice B rationale: Respiratory status must be assessed at least every hour during magnesium sulfate therapy because respiratory depression is a primary sign of magnesium toxicity. Normal adult respiratory rate is 12 to 20 breaths per minute, and a rate below 12/min is concerning. Magnesium depresses the respiratory center in the medulla, and early recognition of hypoventilation is essential to prevent hypoxia and arrest. Thus, frequent respiratory monitoring is a priority nursing action.

Choice C rationale: Monitoring intake and output is essential because magnesium sulfate is excreted almost entirely by the kidneys. Oliguria, defined as urine output less than 30 mL/hr, increases the risk of magnesium accumulation and toxicity. Careful fluid balance assessment ensures adequate renal clearance and helps prevent complications such as pulmonary edema. Therefore, strict I&O monitoring is a critical nursing responsibility during magnesium sulfate therapy to ensure safe drug metabolism and excretion.

Choice D rationale: Intermittent fetal monitoring is not appropriate in this context. Magnesium sulfate administration and preterm labor with rupture of membranes require continuous fetal monitoring to detect early signs of distress. Intermittent monitoring risks missing decelerations or prolonged bradycardia. Continuous monitoring provides real-time assessment of fetal well-being and is the standard of care in high-risk obstetric situations. Therefore, intermittent monitoring is not a correct action and should not be selected.

Choice E rationale: Supine positioning is contraindicated in pregnancy, especially in the third trimester, because the gravid uterus compresses the inferior vena cava, leading to supine hypotensive syndrome. This decreases venous return, cardiac output, and uteroplacental perfusion, compromising both maternal and fetal oxygenation. The correct position is left lateral recumbent to optimize circulation. Therefore, placing the client supine is unsafe and not an appropriate nursing action in this scenario.