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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

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.

A. Mucous membrane assessment B. Sclera color C. Head assessment finding D. Intake and output E. Coombs test result F. Respiratory rate

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.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 preparing to perform a heel stick on a newborn who has a prescription for a total serum bilirubin. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is caring for a newborn who was born at 39 weeks of gestation and is 36 hr old. Exhibits Which finding(s) from the assessment should be reported to the provider for further evaluation or intervention? Select all that apply.

Correct Answer is A

Explanation

A nurse is assessing the results of a nonstress test for an antepartal client at 35 weeks of gestation. Which of the following findings should indicate to the nurse the need for further diagnostic testing?

A nurse is caring for a newborn who has jaundice and a new prescription for phototherapy. Which of the following actions should the nurse take?

A nurse is caring for a client who is in the second stage of labor and is experiencing a shoulder dystocia. The provider instructs the nurse to perform the McRoberts maneuver. Which of the following actions should the nurse take?

A nurse is preparing to administer phytonadione 0.5 mg to a newborn. Which of the following routes should the nurse choose for administration of the medication?

A nurse is reviewing the laboratory results of a client who is at 32 weeks of gestation and has preeclampsia. The nurse should identify that which of the following findings is indicated with HELLP syndrome?

A nurse is planning care for a client who is 12 hr postpartum and has a third-degree perineal laceration. Which of the following interventions should the nurse include in the plan?

A nurse is caring for the client at the next prenatal visit. Exhibits After reviewing the assessment findings, which of the following complications is the client at an Increased risk for developing? Select the 3 complications the client is at an increased risk for developing.