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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A functional assessment is an evaluation of an individual's ability to perform activities of daily living (ADLs), which includes tasks such as bathing, dressing, toileting, eating, and mobility. Falls are a common and significant issue among older adults and are a leading cause of injury and hospitalization. Therefore, it is important to assess the client's risk of falling and inquire about any recent falls to develop an appropriate plan of care to prevent falls.

Encouraging the client to lie as still as possible during the assessment is not appropriate as it may not provide an accurate evaluation of the client's ability to perform ADLs.

Additionally, it is important to assess the client's functional status in a way that is safe and comfortable for them.

Assisting the client with values clarification about end-of-life care options is not appropriate during a functional assessment as it is not directly related to the client's ability to perform ADLs.

Asking the client how often episodes of sundowning are experienced is not appropriate during a functional assessment as sundowning is a symptom of dementia and is not directly related to the client's ability to perform ADLs.

A. Her fasting 1-hour glucose screening level, which was done 1 week prior B. Her 3-hour oral glucose tolerance test results C. a two-hour postprandial of 220 mg/dL

Correct Answer is ["A","B","C"]

Explanation

Her fasting 1-hour glucose screening level, which was done 1 week prior, is 164 mg/dl. (9.1 mmol/L) Her 3-hour oral glucose tolerance test results reveal a fasting blood sugar of 168 (9.3 mmol/L) and a two-hour postprandial of 220 mg/dL (12.2 mmol/L).

The client has gestational diabetes mellitus (GDM), which is a condition that affects some pregnant women and causes high blood sugar levels. This is bad during pregnancy because it can increase the risk of complications for both the mother and the baby, such as preeclampsia, macrosomia, birth trauma, neonatal hypoglycemia, and congenital anomalies. The client needs to follow a diet and exercise plan to control her blood sugar levels and prevent further complications. She may also need to take insulin injections or oral medications if diet and exercise are not enough. The client should monitor her blood sugar levels regularly and report any abnormal results to her health care provider. The client should also have regular prenatal visits and ultrasounds to check the growth and development of the baby.

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Naxlex Comprehensive Predictor Exams

An older client is being admitted to a short-term rehabilitation facility after a long hospitalization. The nurse is performing a functional assessment with the client. Which action should the nurse implement?

Correct Answer is B

Explanation

Correct Answer is ["A","B","C"]

Explanation

The nurse is setting up the equipment to assist with a sigmoidoscopy while the practical nurse (PN) positions the client in a flat prone position. Which action should the nurse implement?

What age-related factors may factor into this client's wound healing? Select all that apply.

Which instruction regarding skin care should the nurse provide to a client who is receiving radiation therapy for metastatic breast cancer?

The nurse is caring for a client with type 2 diabetes and coronary artery disease who is experiencing episodes of confusion. Which finding alerts the nurse that the client may be experiencing a complication?

The nurse is caring for a client who reports running out of aspirin 1 week ago and taking ibuprofen as a replacement. Which information should the nurse obtain from the client first?

When planning care for an adolescent with anorexia nervosa, which nursing problem has the highest priority?

A client with unilateral hearing loss is admitted for a scheduled surgery. Which technique should the nurse use to provide education about pain relief options?