During the assessment of a 35-week gestation client admitted to the obstetrics unit in active labor, the nurse notes the following: estimated fetal weight less than 2500 grams; membranes ruptured 12 hours ago; blood type AB negative; positive rubella
titer; positive vaginal culture for Group B streptococcus; current vital signs: T 99.2°F, P 104, R 26, B/P 128/88 . Identify the most appro-priate action by the nurse at this time.
a. Administer a MMR vaccine.
b. Call the on-call pediatrician to warn him about a premature infant delivery.
c. Order a type and cross-match for two units of blood.
d. Administer an ordered IV antibiotic.
D
You might also like to view...
The organization of a patient's care on the palliative care unit is based on interdisciplinary collaboration. How does interdisciplinary collaboration differ from multidisciplinary practice?
A) It is based on the participation of clinicians without a team leader. B) It is based on clinicians of varied backgrounds integrating their separate plans of care. C) It is based on communication and cooperation between disciplines. D) It is based on medical expertise and patient preference with the support of nursing.
A nurse is caring for a patient who is taking haloperidol. He has orders for a new drug, and the nurse notes that it is highly protein bound. The nurse will plan care based on which of the following?
A) A decreased risk for toxic effects of haloperidol therapy B) An increased risk for toxic effects of haloperidol therapy C) A decreased risk for muscular contractions and spasms D) A high drug efficacy of haloperidol
The first step in the treatment of sleep disorders is to:
a. Teach prevention. b. Give hypnotics for sleep. c. Evaluate sleeping patterns. d. Teach clients to retire early.
A community health nurse is working with a group of homeless individuals with severe mental illness. Which of the following would the nurse need to keep in mind about this population when planning programs?
A) They remain homeless for a shorter period of time. B) There is usually some support from family. C) They experience greater difficulties with employment. D) The majority typically require institutionalization.