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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
This is because lowering the bed reduces the risk of injury if the client falls out of the bed. It also makes it easier for the client to get in and out of the bed safely.
Choice B is wrong because wearing socks when ambulating can increase the risk of slipping and falling. The client should wear shoes or slippers with non-skid soles.
Choice C is wrong because positioning the client’s bedside table at the foot of the bed can create an obstacle for the client to walk around. The bedside table should be placed near the head of the bed and within reach of the client.
Choice D is wrong because raising four side rails on the client’s bed can be considered a form of restraint and can increase the risk of injury if the client tries to climb over them. The use of restraints should be avoided for clients with dementia, as they can cause agitation, confusion, and distress. Instead, other measures such as bed alarms, motion sensors, or frequent monitoring should be used to prevent falls.
Correct Answer is A
Explanation
This statement indicates an understanding of the teaching because babies born to mothers with gestational diabetes mellitus (GDM) are at risk for low blood sugar (hypoglycemia) after birth due to high insulin levels.
Choice B is wrong because a client who has GDM should check their blood glucose more frequently than once every 8 hours. The American Diabetes Association recommends checking blood glucose levels before meals and one hour after the start of each meal.
Choice C is wrong because a baby born to a mother with GDM is at risk for being overweight (macrosomia) at birth, not underweight. This can lead to complications such as shoulder dystocia, birth trauma, and cesarean delivery.
Choice D is wrong because a client who has GDM should ensure that about 15 to 20 percent of their daily calories come from protein sources, not 5 percent. Protein helps regulate blood glucose levels and supports fetal growth.
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