During the first trimester of pregnancy, a client who was treated for genital herpes with acyclovir prior to this pregnancy tells the practical nurse (PN) that she is experiencing an episode of genital herpes.
Which nursing intervention has the highest priority?
Assess her feelings about therapeutic abortions in the event the infant has been affected
Identify current sexual partners so that they can be evaluated and treated for genital herpes if necessary.
Instruct her to avoid sexual intercourse while active, visible lesions are present.
Determine if the client has taken acyclovir for this outbreak of genital herpes.
The Correct Answer is C
A. Assess her feelings about therapeutic abortions in the event the infant has been affected. - While important to address concerns, the immediate priority is to manage the current outbreak and prevent transmission.
B. Identify current sexual partners so that they can be evaluated and treated for genital herpes if necessary. - Contact tracing is important but not the highest priority in managing the current outbreak.
C. Instruct her to avoid sexual intercourse while active, visible lesions are present. - This is crucial to prevent transmission of the herpes virus to the sexual partner and to reduce the risk of complications for the pregnancy.
D. Determine if the client has taken acyclovir for this outbreak of genital herpes. - While important for understanding the treatment history, instructing the client on preventive measures has a higher priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Assess her feelings about therapeutic abortions in the event the infant has been affected. - While important to consider potential outcomes, immediate care involves preventing transmission and managing the current outbreak.
B. Identify current sexual partners so that they can be evaluated and treated for genital herpes if necessary. - Contact tracing is important but not the highest priority in managing the current outbreak.
C. Instruct her to avoid sexual intercourse while active, visible lesions are present. - This is crucial to prevent transmission of the herpes virus to the sexual partner and to reduce the risk of complications for the pregnancy.
D. Determine if the client has taken acyclovir for this outbreak of genital herpes. - While important for understanding the treatment history, instructing the client on preventive measures has a higher priority.
Correct Answer is C
Explanation
A. Checking for kinks in the drainage tubing might be a part of troubleshooting, but the observed clots and thick red fluid require immediate attention, so informing the charge nurse is the priority.
B. Delaying assessment for another hour could potentially exacerbate the issue if there's a problem with the irrigation or if the client's condition worsens.
C. Reporting the finding to the charge nurse is crucial as it indicates potential complications such as bleeding or clot formation that need immediate intervention.
D. Immediately stopping the irrigation solution without proper assessment and guidance could lead to complications and isn't the initial action warranted in this situation.
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