A woman in active labor is receiving intravenous antibiotics for group B streptococcus (GBS) prophylaxis. What maternal assessment finding indicates a potential adverse reaction to the antibiotics?

Correct Answer: B

Rationale: Urticaria (hives) and pruritus (itching) are common signs of an allergic reaction to antibiotics, including those used for GBS prophylaxis during labor. Other signs of an adverse reaction may include flushing, fever, chills, and anaphylaxis. It is important to monitor the woman closely for any signs of an allergic reaction and to intervene promptly if one occurs to ensure the safety of both the mother and the baby.

Correct Answer: A

Rationale: Maternal dehydration can lead to a prolonged latent phase in labor due to inadequate hydration affecting the progress of labor. Dehydration can cause decreased blood volume, leading to poor uterine perfusion and inefficient uterine contractions. It also contributes to reduced amniotic fluid volume and can lead to maternal exhaustion. Therefore, assessment and correction of maternal hydration status are crucial in improving labor patterns and preventing complications during labor and delivery.

Correct Answer: B

Rationale: When a woman in active labor experiences persistent fetal malposition, such as a transverse lie presentation, assisting the mother into a hands-and-knees position is a nursing intervention to prioritize. This position can help encourage the fetus to rotate into a more favorable position for delivery, such as a head-down position. By placing the mother in a hands-and-knees position, gravity can assist in shifting the fetus to the correct position. This intervention is non-invasive and can be effective in promoting the progress of labor and avoiding the need for more invasive interventions like instrumental delivery or cesarean section. However, if the fetus does not rotate or if there are signs of fetal distress, further interventions may be necessary.

Correct Answer: A

Rationale: Proper latch technique is the most important nursing intervention to alleviate nipple soreness in a breastfeeding client. When a baby latches on correctly, it helps prevent nipple trauma and soreness. Educating the client on how to achieve a proper latch, such as ensuring the baby's mouth covers both the nipple and areola, can significantly reduce discomfort during feedings. Improving the latch can also enhance milk transfer, leading to better breastfeeding outcomes for both the mother and baby. While lanolin cream (choice C) can provide some relief for sore nipples, addressing the root cause by correcting the latch is crucial for long-term comfort and successful breastfeeding. Using nipple shields (choice B) or encouraging the use of breast pumps (choice D) should not be the first line of intervention when addressing sore nipples, as they do not address the underlying issue of latch technique.

Correct Answer: A

Rationale: The priority nursing intervention for a postpartum client who experienced a perineal laceration and reports pain and discomfort during defecation is to recommend the use of stool softeners or laxatives. Perineal lacerations can lead to pain and discomfort during bowel movements due to the strain that passing stools may cause on the tender area. Stool softeners or laxatives can help soften the stool, making it easier and less painful for the client to have bowel movements. It is important to alleviate the discomfort and promote bowel regularity to prevent complications such as constipation, which can further exacerbate the pain and delay healing of the perineal laceration.