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 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.
Correct Answer is C
Explanation
A bone scan that is scheduled for today. The nurse should include this information in the change-of-shift report because the oncoming nurse might have to modify the client’s care to accommodate leaving the unit.
Choice A is wrong because the client’s input and output for the shift are routine data that can be found in the client’s chart and do not need to be verbally reported.
Choice B is wrong because the client’s blood pressure from the previous day is not relevant to the current condition of the client and does not reflect any changes or interventions.
Choice D is wrong because the medication routine from the medication administration record is also routine data that can be accessed by the oncoming nurse and does not indicate any special needs or concerns.
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