A nurse is assisting with the care of a client who is in labor with ruptured membranes and has herpes simplex virus with active lesions.
Which of the following actions should the nurse take?

Begin an amnioinfusion for the client.

Prepare the client for a cesarean birth.

Administer ampicillin IV to the client.

Initiate an oxytocin infusion for the client.

Answer and Explanation

The Correct Answer is B

Prepare the client for a cesarean birth.

This is because the client has herpes simplex virus with active lesions, which can be transmitted to the newborn during vaginal delivery and cause serious complications such as neonatal herpes infection. A cesarean birth can prevent this transmission and protect the newborn’s health.

Choice A is wrong because an amnioinfusion is a procedure that involves infusing fluid into the amniotic cavity to increase the volume of amniotic fluid and reduce cord compression.

It is not indicated for a client with herpes simplex virus with active lesions.

Choice C is wrong because ampicillin is an antibiotic that is used to treat bacterial infections, not viral infections such as herpes simplex virus.

Ampicillin will not prevent the transmission of herpes simplex virus to the newborn.

Choice D is wrong because oxytocin is a hormone that stimulates uterine contractions and can be used to augment or induce labor.

It is not indicated for a client with herpes simplex virus with active lesions, as it can increase the risk of transmission to the newborn by prolonging the exposure to infected genital secretions.

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Correct Answer is C

Explanation

The correct answer is choice C. Allergy to gelatin is a contraindication for the inactivated influenza vaccine because gelatin is one of the ingredients in the vaccine. People with severe, life-threatening allergies to any ingredient in a flu vaccine (other than egg proteins) should not get that vaccine.

Choice A is wrong because pregnancy is not a contraindication for the inactivated influenza vaccine. In fact, pregnant people are recommended to get a flu shot because they are at higher risk of developing serious flu complications.

Choice B is wrong because immunosuppression is not a contraindication for the inactivated influenza vaccine. People with weakened immune systems can get a flu shot, but they should avoid the nasal spray flu vaccine which contains live viruses.

Choice D is wrong because moderate illness with fever is not a contraindication for the inactivated influenza vaccine. People who are moderately ill can still get a flu shot, but they should wait until they recover if they have a severe illness.

A. “Record your urination times for 24 hours before beginning the program.” B. “Drink 4 liters of fluid between 6:00 a.m. and 8:00 p.m.” C. “Void every 2 hours while awake.” D. “Eliminate caffeine from your diet.”

Correct Answer is A

Explanation

This instruction helps the client to establish a baseline of their bladder function and identify their voiding patterns. It also helps the nurse to design an individualized bladder-training program for the client.

Choice B is wrong because drinking 4 liters of fluid between 6:00 a.m. and 8:00 p.m. is excessive and can increase the frequency and urgency of urination. The client should drink enough fluids to prevent dehydration and constipation, but avoid drinking large amounts at one time or before bedtime.

Choice C is wrong because voiding every 2 hours while awake is not a bladder- training technique, but a scheduled toilet trip. Bladder training requires following a fixed voiding schedule and delaying urination after feeling the urge to go. Voiding every 2 hours may not allow the bladder to fill sufficiently and may interfere with the goal of increasing the bladder capacity.

Choice D is wrong because eliminating caffeine from the diet is not a specific instruction for bladder training, but a general lifestyle strategy to ease bladder problems. Caffeine can irritate the bladder and act as a diuretic, which can increase urine production and frequency.

However, eliminating caffeine alone may not be enough to improve urinary incontinence.

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A nurse is assisting with the care of a client who is in labor with ruptured membranes and has herpes simplex virus with active lesions. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

A nurse is administering the inactivated influenza vaccine to a group of clients at a health clinic. The nurse should recognize that which of the following conditions is a contraindication for this vaccine?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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A nurse is assisting with the care of a client who is in labor with ruptured membranes and has herpes simplex virus with active lesions.
Which of the following actions should the nurse take?