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
Contact information for a community mental health center. A community mental health center can provide ongoing outpatient care and support services for a client who has schizophrenia after discharge from an inpatient unit. A community mental health center can also help the client access other resources such as medication, housing, and vocational training.
Choice B is wrong because a list of primary prevention activities is not relevant for a client who already has schizophrenia. Primary prevention aims to prevent the occurrence of a disease or disorder in the first place.
Choice C is wrong because contact information for enrollment in a 12-step program is not appropriate for a client who has schizophrenia unless they also have a substance use disorder. A 12-step program is a self-help group that follows a set of principles to achieve and maintain sobriety.
Choice D is wrong because a referral for respite care services is not necessary for a client who has schizophrenia unless they also have a caregiver who needs temporary relief from their caregiving duties. Respite care services provide short-term care for clients who are dependent on others for their daily needs.
Correct Answer is D
Explanation
Place the newborn on a flat surface and clap hands loudly.
This action will elicit the Moro reflex, also known as the startle reflex, which is a normal, involuntary reaction that newborns and infants have when they’re startled. In response to the sound, the baby will throw back his or her head, extend out his or her arms and legs, cry, then pull the arms and legs back in.
Choice A is wrong because placing the newborn on their abdomen and observing the movement of their extremities will not trigger the Moro reflex.
This position may elicit other reflexes such as the crawling reflex or the tonic neck reflex.
Choice B is wrong because stroking the newborn’s cheek toward their mouth will not trigger the Moro reflex. This action will elicit the rooting reflex, which helps the baby find the breast or bottle to start feeding.
Choice C is wrong because stroking upward on the lateral aspect of the newborn’s foot will not trigger the Moro reflex. This action will elicit the Babinski reflex, which causes the big toe to extend upward and the other toes to fan out.
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