A nurse is caring for a client in labor who has herpes simplex virus (HSV) with active lesions. Which of the following interventions should the nurse plan to implement to prevent the transmission of HSV to the newborn?

Apply cortisone ointment on the lesions prior to birth.

Administer erythromycin ointment in the newborn's eyes after birth.

Anticipate a scheduled cesarean birth.

Initiate IV penicillin G during the labor.

Answer and Explanation

The Correct Answer is C

A. Apply cortisone ointment on the lesions prior to birth:

Cortisone ointment is not appropriate for the treatment of herpes simplex virus (HSV) lesions. Cortisone is a steroid medication that can suppress the immune response, potentially worsening the HSV infection. Additionally, cortisone ointment does not directly treat the virus or prevent its transmission. Therefore, applying cortisone ointment on the lesions would not be effective and could even be harmful to both the mother and the newborn.

B. Administer erythromycin ointment in the newborn's eyes after birth:

Erythromycin ointment is routinely used in newborns to prevent bacterial eye infections, such as those caused by Chlamydia trachomatis or Neisseria gonorrhoeae. However, it is not effective against viruses like HSV. Therefore, while erythromycin ointment is important for preventing bacterial infections in newborns, it does not address the risk of HSV transmission from the mother to the newborn during birth.

C. Anticipate a scheduled cesarean birth:

When a pregnant person has active genital herpes lesions near the time of delivery, a scheduled cesarean section (C-section) is often recommended to reduce the risk of neonatal herpes transmission. Delivering the baby via C-section can decrease the likelihood of the newborn coming into contact with the virus in the birth canal, thereby reducing the risk of neonatal herpes infection. This intervention is specifically targeted at preventing HSV transmission to the newborn and is considered the standard of care in such situations.

D. Initiate IV penicillin G during labor:

Penicillin G is an antibiotic used to treat bacterial infections, but it is not effective against viruses like HSV. Therefore, initiating IV penicillin G during labor would not prevent the transmission of HSV to the newborn. While antibiotics may be used in certain situations during labor to prevent bacterial infections, they do not address the risk of HSV transmission and are not indicated for this purpose.

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Correct Answer is A

Explanation

A.Dry mucous membranes may indicate dehydration. The newborn is breastfeeding only 3–4 times per day, which is lower than the recommended 8–12 feedings per day for adequate hydration and nutrition.

B.Yellow sclera suggests jaundice, which could indicate neonatal hyperbilirubinemia. Since the newborn is Coombs-positive, there is an increased risk of hemolytic disease of the newborn (HDN) due to blood incompatibility, making bilirubin monitoring essential.

D.The newborn has voided only once in 36 hours, which may indicate dehydration or inadequate fluid intake. Additionally, the absence of a meconium stool may suggest intestinal obstruction, delayed passage, or meconium plug syndrome, requiring further evaluation.

E.A positive Coombs test means that maternal antibodies have attacked the newborn’s red blood cells, increasing the risk of hemolytic anemia and jaundice. This finding correlates with the yellow sclera, necessitating further bilirubin monitoring.

Incorrect answers:

C.Caput succedaneum is benign and self-resolving. It is a soft tissue swelling from birth trauma and does not require intervention.

F.A respiratory rate of 44 breaths/min is within the normal range (30–60 breaths/min) for a newborn and does not indicate distress.

A. Heart rate 110/min B. Blood pressure 104/66 mm Hg C. Hemoglobin 10.2 g/dL D. Potassium 3.3 mEq/L E. BUN 28 mg/dL F. Urine specific gravity 1.045 G. Decreased skin turgor H. WBC count 7,500/mm3 I. Client reports vomiting several times a day over the last 2 weeks J. Color dark amber

Correct Answer is ["A","C","D","E","F","G","I","J"]

Explanation

Heart rate 110/min
Correct (requires follow-up) – A heart rate of 110/min is elevated, which could indicate dehydration or other physiological stress, such as hyperemesis gravidarum.
Blood pressure 104/66 mm Hg
Wrong (does not require follow-up) – This blood pressure is within normal limits, particularly in pregnancy, where slight decreases in blood pressure are common.
Hemoglobin 10.2 g/dL
Correct (requires follow-up) – This is lower than the normal range (11 to 16 g/dL) and indicates mild anemia, which should be monitored during pregnancy.
Potassium 3.3 mEq/L
Correct (requires follow-up) – This potassium level is below the normal range (3.5 to 5 mEq/L), indicating hypokalemia, likely due to vomiting. Hypokalemia needs correction as it can cause complications.
BUN 28 mg/dL
Correct (requires follow-up) – Blood urea nitrogen (BUN) is elevated (normal range 10 to 20 mg/dL), which could indicate dehydration, a concern especially with vomiting and reduced intake.
Urine specific gravity 1.045
Correct (requires follow-up) – This is higher than the normal range (1.005 to 1.03), suggesting concentrated urine and potential dehydration.
Decreased skin turgor
Correct (requires follow-up) – Decreased skin turgor is a physical sign of dehydration and should be addressed, especially considering the client's vomiting.
WBC count 7,500/mm3
Wrong (does not require follow-up) – The WBC count is within the normal range (5,000 to 10,000/mm3), so it does not indicate an infection or other abnormalities.
Client reports vomiting several times a day over the last 2 weeks
Correct (requires follow-up) – Persistent vomiting over this time period is concerning for hyperemesis gravidarum and could lead to complications such as dehydration and electrolyte imbalances.
Urine color dark amber
Correct (requires follow-up) – Dark amber urine could be a sign of dehydration, especially in combination with an elevated urine specific gravity.

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A nurse is caring for a client in labor who has herpes simplex virus (HSV) with active lesions. Which of the following interventions should the nurse plan to implement to prevent the transmission of HSV to the newborn?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Explanation

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