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]
Transfuse two units packed red blood cells.
Administer ampicillin 2 grams intravenously.
Inject hepatitis B immune globulin 0.5 mL.
Give measles, mumps, rubella vaccine 0.5 mL.
The Correct Answer is B
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Incorrect- Anal abscesses and fistulas are more commonly associated with Crohn's disease than with ulcerative colitis. Crohn's disease can involve the entire thickness of the bowel wall and create tunnels or connections (fistulas) between different parts of the gastrointestinal tract.
B) Correct- Rectal bleeding is a common symptom of ulcerative colitis, as the inflamed tissue can bleed easily.
C) Incorrect- Constipation is not a common characteristic of Crohn's disease. In fact, both ulcerative colitis and Crohn's disease can lead to a range of bowel habits, including diarrhea and constipation, depending on the extent and location of inflammation.
D) Incorrect- Both ulcerative colitis and Crohn's disease are inflammatory bowel diseases (IBD) that involve chronic inflammation of the gastrointestinal tract. Ulcerative colitis primarily affects the colon and rectum, causing continuous areas of inflammation and ulceration. Crohn's disease can affect any part of the gastrointestinal tract, from the mouth to the anus. It often involves patches of inflammation with healthy tissue in between, and it can affect different layers of the bowel wall.
Correct Answer is A
Explanation
The Ortolani maneuver is a physical examination technique used to assess for developmental dysplasia of the hip (DDH) in newborns. During the maneuver, the nurse gently abducts the infant's hips and applies gentle pressure to detect any instability or "click" at the hip joint. A positive Ortolani maneuver, where a click or clunk is felt or heard, can indicate the presence of a hip dislocation or dysplasia.
Asymmetrical buttocks can be a sign of hip dysplasia in newborns, and a positive Ortolani maneuver is an important finding that suggests a potential hip joint problem. Reporting this assessment test result to the healthcare provider allows for further evaluation and appropriate management of the newborn's hip condition.
The Plumb line test, which assesses fetal position curvature, is not directly related to hip dysplasia and may not be significant in this context.
The Babinski test, which reveals fanning out of the toes, is used to assess the integrity of the infant's neurological system and is not specific to hip dysplasia.
The Moro test, also known as the startle response, is a reflex assessment used to evaluate the newborn's neurological and sensory function. While it is important to assess the overall neurological status of the newborn, the Moro test is not specific to hip dysplasia.
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