A multiparous client with active herpes lesions has been admitted to the unit due to spontaneous rupture of membranes.
What action should the nurse take?

Cover the lesion with a dressing.

Prepare for a cesarean section.

Obtain blood cultures.

Administer penicillin.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Covering the lesion with a dressing is not the standard care for a pregnant client with active herpes lesions. Herpes can be transmitted to the baby during a vaginal birth, even if lesions are covered.

Choice B rationale

Preparing for a cesarean section is the correct action. A cesarean section is often recommended for women with active genital herpes lesions to prevent transmission of the virus to the baby during delivery.

Choice C rationale

Obtaining blood cultures is not typically necessary for a client with active herpes lesions. Herpes is a viral infection, and its presence is usually determined through a visual examination of lesions and sometimes a swab of the lesion, not through blood cultures.

Choice D rationale

Administering penicillin is not the correct action. Penicillin is an antibiotic, which is used to treat bacterial infections, not viral infections like herpes.

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Correct Answer is A

Explanation

Choice A rationale

In a situation where a client at 28 weeks gestation is in preterm labor and it is not expected that the fetus will survive after delivery, the nurse’s initial action should be to contact spiritual support services. This can provide much-needed emotional and spiritual support to the client during this difficult time.

Choice B rationale

While providing information about an autopsy might be necessary at some point, it should not be the initial action. The first response should be focused on providing emotional support.

Choice C rationale

Discussing neonatal resuscitation options might not be appropriate in this scenario, especially if it’s not expected that the fetus will survive. The initial focus should be on providing emotional support.

Choice D rationale

Contacting the organ donation organization is not the initial action to take in this situation. The first response should be providing emotional and spiritual support to the client.

A. Hegar’s sign. B. Breast tenderness. C. Amenorrhea. D. Morning sickness.

Correct Answer is C

Explanation

Choice C rationale

Amenorrhea, or the absence of menstruation, is often the first and most reliable sign of pregnancy. If a woman is in her childbearing years and a week or more has passed without the start of an expected menstrual cycle, she might be pregnant.

Choice A rationale

Hegar’s sign is a physical examination finding that can be indicative of pregnancy. However, it is not typically used as the primary indicator of pregnancy because it requires a pelvic examination and is less reliable than other signs such as amenorrhea.

Choice B rationale

While breast tenderness can be a symptom of early pregnancy, it is not the most reliable indicator. Many other conditions or factors, such as hormonal fluctuations related to the menstrual cycle, can also cause breast tenderness.

Choice D rationale

Morning sickness, characterized by nausea and vomiting, is a common symptom of early pregnancy. However, not all pregnant women experience morning sickness, and it can also be caused by other conditions. Therefore, it is not the most reliable indicator of pregnancy.

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A multiparous client with active herpes lesions has been admitted to the unit due to spontaneous rupture of membranes.What action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client at 28 weeks gestation is in preterm labor and it is not expected that the fetus will survive after delivery. What should be the nurse’s initial action?

Correct Answer is A

Explanation

A client informs the nurse that she believes she is pregnant. Which sign or symptom is the best indicator that the client is pregnant?

Correct Answer is C

Explanation

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A multiparous client with active herpes lesions has been admitted to the unit due to spontaneous rupture of membranes.
What action should the nurse take?