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) Incorrect- While it's important for UAPs to report changes in a client's condition, the immediate priority is to assess and address the deteriorating condition of the client. The nurse's first action should be to stop the current care being provided and assess the client.
B) Correct- In this situation, the priority is to ensure the safety and well-being of the client. The client's deteriorated condition needs to be assessed promptly by a licensed nurse to determine the appropriate interventions. Stopping the care being provided by the unlicensed assistive personnel (UAP) allows the nurse to focus on the client's immediate needs.
C) Incorrect- Administering oral medications is not the immediate priority in this situation. The client's deteriorating condition takes precedence over administering medications.
D) Incorrect- While investigating the situation and addressing communication gaps is important, the first priority is to assess and address the client's current condition. The nurse needs to take immediate action to ensure the client's safety and well-being.

A. Encourage the use of ice on the areola. B. Teach about the use of a breast pump. C. Offer supplemental formula feedings. D. Recommend using a breast shield.

Correct Answer is B

Explanation

The correct answer is Choice B.

Choice A rationale: Ice application induces vasoconstriction, which reduces swelling but does not evert inverted nipples. This action does not address the primary issue of nipple inversion preventing adequate latch.

Choice B rationale: Breast pump use creates negative pressure, drawing out the nipple. This eversion facilitates latching by providing a more prominent nipple for the infant's oral cavity to grasp effectively.

Choice C rationale: Supplemental formula feedings provide nutrition, but do not resolve the latching difficulty caused by inverted nipples. This can interfere with the establishment of the mother's milk supply.

Choice D rationale: Breast shields can aid latching, but they are most effective when used in conjunction with nipple eversion techniques. They do not directly address the underlying problem of inverted nipples.

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A client who is one day postpartum tells the nurse that her baby cannot latch onto the breast. The nurse determines that the client's nipples are inverted. Which action should the nurse implement?

Correct Answer is B

Explanation

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