A nurse is planning care for a newborn who was exposed to active genital herpes simplex virus (HSV) during birth.
Which of the following nursing actions should the nurse anticipate?

Choice A rationale

Feeding from only one breast can lead to engorgement and a decrease in milk supply in the affected breast. It is important to continue breastfeeding from both breasts, even if one is infected.

Choice B rationale

Discarding milk is not necessary and can lead to a decrease in milk supply. The infection does not harm the baby, and breastfeeding helps to drain the breast and clear the infection.

Choice C rationale

Moist heat can help to increase blood flow and promote healing in the affected breast. Applying warm compresses or taking warm showers can help to reduce pain and inflammation associated with mastitis.

Choice D rationale

While staying hydrated is important for overall health, there is no specific requirement to drink at least 1500 milliliters of fluid per day for mastitis. Adequate fluid intake should be maintained, but there is no direct correlation with resolving the infection.

The nurse should identify that the client is at the greatest risk for preterm birth due to:

Response 1: B) being higher than normal (fetal fibronectin: 0.09 mcg/mL is higher than the normal level of ≤ 0.05 mcg/mL).

Response 2: B) Nitrazine and ferning tests negative

Here's the

• Fetal Fibronectin: Fetal fibronectin is a protein found between the amniotic sac and the uterine lining. Levels greater than 0.05 mcg/mL (like 0.09 mcg/mL) indicate an increased risk of preterm labor.
• Nitrazine and Ferning Tests: Both tests being negative indicates that there is no rupture of membranes. Even though these tests are negative, the elevated fetal fibronectin level still indicates a risk for preterm birth.

So the completed sentence would be: The nurse should identify that the client is at the greatest risk for preterm birth due to fetal fibronectin being higher than normal and Nitrazine and ferning tests negative.

This combination of findings suggests that preterm labor may be imminent despite the lack of membrane rupture. The elevated fetal fibronectin is a strong indicator of risk.