A primiparous woman presents in labor with the following labs: hemoglobin 10.9 g/dL (109 g/L), hematocrit 29% (0.29), hepatitis surface antigen positive, group B Streptococcus positive, and rubella non- immune.

Which intervention should the nurse implement?

Reference Range

• Hemaglobin [Reference Range:12-16 g/dL (120-160 g/L)]
• Hematrocrit [Reference Range:Pregnant female: 37% to 47% (0.37 to 0.47 volume fraction)] Hepatitis Surface Antigen [Reference Range: negative]
• Group B Streptococcus [Reference Range: negative]

The client's labs indicate that she has a positive result for group B Streptococcus (GBS) and hepatitis surface antigen, and she is also identified as rubella non-immune.

Ampicillin is the recommended antibiotic for intrapartum prophylaxis against GBS infection to reduce the risk of transmission to the newborn. Administering ampicillin intravenously would help protect the newborn from potential GBS-related complications. Transfusion of packed red blood cells is not indicated based on the hemoglobin and hematocrit values provided. The client's hemoglobin and hematocrit levels, although lower than the reference range, are not critically low and do not necessarily require a blood transfusion.

Injecting hepatitis B immune globulin is not the appropriate intervention in this case. The client is positive for hepatitis surface antigen, indicating active infection, and requires appropriate medical management, which may include antiviral treatment.

Administering the measles, mumps, rubella vaccine is contraindicated during pregnancy. Vaccination for rubella is typically recommended prior to conception or postpartum to prevent congenital rubella syndrome.

Given the client's difficulty with memory, concentration, and recent life changes, it is

important for the nurse to acknowledge the possibility of delirium as a potential cause of the client's symptoms. Delirium is an acute state of confusion that can be caused by various factors, including physical illness, medication side effects, and emotional stressors. It is often reversible when the underlying cause is identified and treated.

By mentioning the possibility of delirium and its potential reversibility, the nurse opens up the conversation to exploring other factors that may be contributing to the client's symptoms. This response also provides hope to the family by suggesting that the client's condition may improve with appropriate interventions and management.

Stating that dementia resulting from Alzheimer's disease is often reversible even in the late stages is incorrect. Alzheimer's disease is a progressive neurodegenerative disorder that currently has no cure, and the symptoms tend to worsen over time.

Reversibility is not typically associated with Alzheimer's disease.

Indicating that the client's symptoms of dementia are permanent due to age is a generalization and may not be accurate. While age is a risk factor for certain types of dementia, such as Alzheimer's disease, it does not mean that all memory and cognitive difficulties in older adults are irreversible.

Suggesting that delirium is often a sign of underlying mental illness and institutionalization is necessary is not appropriate. Delirium is a medical condition that requires thorough assessment and appropriate management, including addressing any underlying causes. Institutionalization may be considered in certain situations, but it is not the primary focus of communication in this context.