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 ["D","E"]

Explanation

A. Abdominal distention:

Abdominal distention is not typically associated with hypoglycemia in newborns. It may be caused by other factors such as swallowed air during feeding or gastrointestinal issues.

B. Acrocyanosis:

Acrocyanosis, which is the blueness of the hands and feet, is a common finding in newborns and is not specific to hypoglycemia. It is often a result of the newborn's immature circulatory system.

C. Temperature instability:

Temperature instability, including hypothermia or hyperthermia, can occur in newborns for various reasons, but it is not specific to hypoglycemia.

D. Hypotonia:

Hypotonia, or decreased muscle tone, can be a sign of hypoglycemia in newborns. It may present as decreased activity, floppy movements, or poor feeding.

E.Jitteriness

Jitteriness, which is characterized by tremors or shaky movements, is a common manifestation of hypoglycemia in newborns. It is often observed when the newborn's blood glucose levels are low and can be a significant sign of hypoglycemia.

A. Place a cool cloth at the site for 15 min before the procedure. B. Apply an alcohol pad to the site after the procedure. C. Puncture the lateral side of the heel for the procedure. D. Select a 21-gauge needle to perform the procedure.

Correct Answer is C

Explanation

A. Place a cool cloth at the site for 15 min before the procedure:

Placing a cool cloth at the site before the procedure is not typically done for a heel stick in newborns. In fact, applying cold to the site can cause vasoconstriction, which may make it more difficult to obtain an adequate blood sample. Additionally, cooling the area can potentially lead to discomfort for the newborn. Therefore, this action is not recommended and would not be appropriate in this scenario.

B. Apply an alcohol pad to the site after the procedure:

While alcohol pads are commonly used for disinfection before certain procedures, they are not typically used after a heel stick to obtain a blood sample for a total serum bilirubin test. Alcohol can interfere with bilirubin testing by altering the bilirubin levels in the blood, leading to inaccurate results. Therefore, applying an alcohol pad after the procedure is not recommended, particularly for bilirubin testing.

C. Puncture the lateral side of the heel for the procedure:

When performing a heel stick on a newborn, it is important to choose the appropriate site for puncture. The lateral side of the heel is preferred over the medial side because it has fewer nerves and blood vessels, reducing the risk of complications and discomfort for the newborn. Puncturing the lateral side also allows for a more controlled and successful blood draw. Therefore, this choice is the most appropriate for obtaining a blood sample for a total serum bilirubin test.

D. Select a 21-gauge needle to perform the procedure:

The choice of needle gauge for a heel stick in a newborn depends on various factors, including the size of the newborn's heel and the desired blood flow rate. However, a 21-gauge needle is relatively large and may cause more pain and tissue trauma compared to smaller gauge needles, especially in newborns. Smaller gauge needles, such as 23 or 25 gauge, are typically preferred for heel sticks in newborns to minimize discomfort and trauma to the tissue. Therefore, selecting a 21-gauge needle may not be the most appropriate choice for this procedure.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a newborn who is 2 hr old. Which of the following findings is an indication of hypoglycemia? (Select all that apply.)

Correct Answer is ["D","E"]

Explanation

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Correct Answer is C

Explanation

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