A multiparous client with active herpes lesions is admitted to the unit with spontaneous rupture of membranes. Which action should the nurse take?

Prepare for a cesarean section

Cover the lesion with a dressing

Obtain blood cultures

Administer penicillin.

Answer and Explanation

The Correct Answer is A

Prepare for a cesarean section:Active herpes lesions are a contraindication for vaginal delivery due to the risk of transmitting the herpes simplex virus (HSV) to the newborn. A cesarean section is necessary to prevent the baby from coming into direct contact with the herpes lesions and reduce the risk of neonatal herpes infection.

Cover the lesion with a dressing:While covering the lesion might be part of overall care, it does not address the primary concern of preventing transmission to the newborn during delivery.

Obtain blood cultures:
Obtaining blood cultures may not be the primary action in this situation. The concern is more related to preventing the transmission of the herpes virus to the newborn.

Administer penicillin:
Penicillin is not the treatment for herpes. Antiviral medications such as acyclovir are typically used for the treatment of herpes infections.

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Correct Answer is A

Explanation

A. Obtain a drug screen for cocaine: Given the symptoms described (tremulous, tachycardic, hypertensive), there may be concern about drug exposure, and cocaine is a substance known to cause such symptoms in newborns. Therefore, obtaining a drug screen for cocaine is a reasonable and important action to determine if there was prenatal exposure.

B. Weigh and measure the newborn: While weighing and measuring the newborn is a routine part of the newborn assessment, it may not be the most crucial action in this context. The symptoms described suggest the need for a more immediate assessment related to possible drug exposure.

C. Determine reactivity of neonatal reflexes: Assessing the reactivity of neonatal reflexes is an important part of the newborn assessment, but in this specific situation, the symptoms described (tremulous, tachycardic, hypertensive) may warrant a more focused and immediate assessment related to drug exposure.

D. Perform gestational age assessment: Gestational age assessment is essential for understanding the newborn's maturity and adjusting care accordingly. However, in this scenario, the immediate concern seems to be the symptoms the newborn is presenting with, and addressing the possibility of drug exposure takes precedence.

A. dilate the pupil so the red reflex can be visualized B. prevent herpes infection. C. prevent eye infections D. clear the infant's vision

Correct Answer is C

Explanation

A. Dilate the pupil so the red reflex can be visualized:
This statement is not accurate regarding the purpose of the eye ointment. The eye ointment is not used to dilate the pupil but serves a different purpose.

B. Prevent herpes infection:
While eye ointment can help prevent certain eye infections, it's not specifically administered to prevent herpes infection.

C. Prevent eye infections:
This is the correct answer. The eye ointment typically contains an antibiotic and is applied to prevent infections, particularly those that could be transmitted during childbirth.

D. Clear the infant's vision:
The eye ointment is not used to clear the infant's vision. Its primary purpose is to prevent infections rather than affect vision.

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A multiparous client with active herpes lesions is admitted to the unit with spontaneous rupture of membranes. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a newborn who was precipitously delivered at 38-weeks gestation The newborn is tremulous, tachycardic, and hypertensive. Which assessment action is most important for the nurse to implement?

Correct Answer is A

Explanation

A father watching the admission of his newborn to the nursery notices that eye ointment is placed in the infant's eyes. He asks the nurse what is the purpose of the ointment. The nurse would be correct in stating that the purpose for using the ointment is to

Correct Answer is C

Explanation

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