A nurse is teaching a client who has a history of genital herpes and is at 32 weeks of gestation. Which of the following statements should the nurse include in the teaching?
"A caesarean birth is the only way to prevent transmission."
"If you notice genital tingling be sure to notify your provider."
"Hydrotherapy during labor can help reduce transmission."
"The provider will perform weekly visual inspections for lesions."
The Correct Answer is B
A. "A cesarean birth is the only way to prevent transmission." Cesarean delivery is considered if active lesions or prodromal symptoms are present at the time of labor. However, it is not automatically required for all clients with a history of herpes.
B. "If you notice genital tingling be sure to notify your provider." Genital tingling or burning can be a prodromal sign of an impending herpes outbreak. Early reporting allows for appropriate evaluation and potential antiviral treatment to reduce the risk of transmission to the newborn.
C. "Hydrotherapy during labor can help reduce transmission." Hydrotherapy has no effect on herpes virus transmission and is not used for this purpose. Preventing neonatal herpes depends on careful monitoring and antiviral management.
D. "The provider will perform weekly visual inspections for lesions." Routine weekly inspections are not standard unless symptoms suggest an outbreak. Clients are generally monitored and evaluated for lesions closer to labor or if symptoms arise.
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Related Questions
Correct Answer is C
Explanation
A. Schedule the client for an aPTT test. An aPTT (activated partial thromboplastin time) test is used to monitor heparin therapy and is not relevant following an amniocentesis unless the client has a known bleeding disorder, which is not indicated here.
B. Collect a blood sample from the client for a direct Coombs test. The direct Coombs test is typically performed on newborns, not the mother, to detect antibodies attached to red blood cells. It is not a routine part of post-amniocentesis care.
C. Monitor the client for uterine contractions. After an amniocentesis, it is essential to monitor for signs of preterm labor, including uterine contractions. The procedure can irritate the uterus and potentially trigger contractions, especially at 34 weeks gestation.
D. Administer Rho(D) Immune globulin if the client is Rh positive. Rho(D) Immune globulin is given to Rh-negative clients after procedures like amniocentesis to prevent isoimmunization. It is not indicated for Rh-positive individuals.
Correct Answer is A
Explanation
A. Measure the tubing from the nose to the distal port. Proper placement of an NG tube requires measuring from the tip of the nose to the earlobe, then to the xiphoid process. This ensures the tube reaches the stomach without curling or entering the airway.
B. Position the child at a 10 to 20 angle after feeding. A head elevation of at least 30 to 45 degrees is necessary during and after NG feedings to reduce the risk of aspiration. A 10 to 20 degree angle is too low and unsafe for post-feeding positioning.
C. Complete the feeding in 5 min. NG feedings should be given slowly over 20 to 30 minutes to prevent gastrointestinal discomfort, cramping, or vomiting. A 5-minute infusion is too rapid and may overwhelm the child’s digestive capacity.
D. Warm the formula in the microwave. Microwaving formula can lead to uneven heating and hot spots, which pose a burn risk to the child. Formula should be warmed by placing the container in warm water and testing the temperature before administration.
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