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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Turn the newborn every 4 hr:
Turning the newborn every 4 hours is a routine nursing intervention to prevent pressure ulcers in infants. However, it is not specifically related to phototherapy treatment. Turning the newborn should be done as per routine care, but it is not a direct action related to phototherapy.
B. Close the newborn's eyes before applying eyepatches:
It is important to protect the newborn's eyes from the bright light used in phototherapy. Therefore, closing the newborn's eyes before applying eyepatches or covering them with eye protection is necessary during phototherapy to prevent eye damage.
C. Provide the newborn with 15 mL glucose water after each feeding:
Providing glucose water after each feeding is not a standard practice for newborns undergoing phototherapy. Instead, the primary focus during phototherapy is on feeding the baby adequately to promote hydration and excretion of bilirubin through stool and urine. Glucose water is not routinely recommended unless specifically ordered by the healthcare provider for a medical indication.
D. Apply hydrating lotion to the newborn's skin prior to treatment:
Hydrating lotion should not be applied to the newborn's skin prior to phototherapy. Lotions, oils, or creams can interfere with the effectiveness of phototherapy by creating a barrier that blocks the light from reaching the baby's skin. Therefore, it is essential to keep the baby's skin clean and free from lotions or ointments during phototherapy.
Correct Answer is D
Explanation
. A client who reports lochia rubra requiring changing perineal pads every 3 hr:
This finding is consistent with normal postpartum lochia patterns, particularly in the early postpartum period. Lochia rubra is the initial bright red vaginal discharge that occurs after childbirth, and changing perineal pads every 3 hours is within the expected range. There is no immediate concern requiring notification of the provider for this client.
B. A client who reports abdominal cramping during breastfeeding:
Abdominal cramping during breastfeeding, also known as afterpains, is a common occurrence in the postpartum period, especially for multiparous clients. These cramps are caused by the release of oxytocin during breastfeeding and help the uterus to contract and return to its pre-pregnancy size. While uncomfortable, afterpains are considered normal and do not typically require notification of the provider unless they are severe or accompanied by other concerning symptoms.
C. A client who has a urinary output of 300 mL in 8 hr:
This urinary output is below the expected range for a postpartum client, and it may indicate inadequate fluid intake, urinary retention, or other issues. While it is important to monitor urinary output and address any potential concerns, this finding alone may not require immediate notification of the provider. However, continued monitoring and assessment are warranted to ensure adequate urinary function.
D. A client who is receiving magnesium sulfate and has absent deep tendon reflexes:
Absent deep tendon reflexes are an indication of magnesium toxicity, which is a serious complication of magnesium sulfate administration. Magnesium sulfate is commonly used to prevent seizures in clients with preeclampsia or eclampsia. However, excessive levels of magnesium can lead to respiratory depression, cardiac arrest, and other adverse effects. Absent deep tendon reflexes are an early sign of magnesium toxicity and require immediate intervention, including discontinuation of magnesium sulfate and close monitoring of the client's respiratory and cardiac status. Therefore, the nurse should notify the provider immediately for further guidance and management.

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