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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Chromosomal abnormalities:
While an ultrasound can sometimes identify structural abnormalities, it's not the primary tool for detecting chromosomal abnormalities. Genetic testing or procedures like amniocentesis are more specific for this purpose.
B. Sex and size of the infant:
An ultrasound is indeed used to determine the sex of the baby and assess its size and growth.
C. Lecithin-sphingomyelin ratio:
The lecithin-sphingomyelin ratio is typically assessed in tests related to fetal lung maturity, which is not the primary purpose of a routine ultrasound.
D. Fetal growth and gestational age:
This is one of the primary purposes of a routine ultrasound during pregnancy. It helps evaluate the baby's growth and ensures it aligns with the expected gestational age.
Correct Answer is C
Explanation
Explain reasons consent for an infant autopsy is needed:
Autopsy might be necessary for understanding the cause of fetal demise, providing answers to the parents, and helping future pregnancies. However, it's not the most immediate or essential action in this scenario.
Determine if the mother desires a visit from her clergy:
Spiritual and emotional support is crucial during this distressing time. While clergy support is valuable, it's not the most urgent action needed immediately after delivery.
Encourage the mother to hold and spend time with her baby:
This is a crucial part of the grieving process and helps in acknowledging and creating memories with the baby. It's an essential step in providing emotional support to the mother.
Create a memory box of baby's footprints and photographs:
This is also a critical step in assisting the parents with the grieving process. It helps in cherishing the memories and creating keepsakes that may provide comfort in the future.
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