A multiparous client with active herpes lesions has been admitted to the unit due to spontaneous rupture of membranes.
What action should the nurse take?

Cover the lesion with a dressing.

Prepare for a cesarean section.

Obtain blood cultures.

Administer penicillin.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Covering the lesion with a dressing is not the standard care for a pregnant client with active herpes lesions. Herpes can be transmitted to the baby during a vaginal birth, even if lesions are covered.

Choice B rationale

Preparing for a cesarean section is the correct action. A cesarean section is often recommended for women with active genital herpes lesions to prevent transmission of the virus to the baby during delivery.

Choice C rationale

Obtaining blood cultures is not typically necessary for a client with active herpes lesions. Herpes is a viral infection, and its presence is usually determined through a visual examination of lesions and sometimes a swab of the lesion, not through blood cultures.

Choice D rationale

Administering penicillin is not the correct action. Penicillin is an antibiotic, which is used to treat bacterial infections, not viral infections like herpes.

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Correct Answer is A

Explanation

Choice A rationale

A client who is 3 weeks postpartum and feeling tired all the time is a common scenario. Adjusting to a new baby can be challenging and it’s normal for new mothers to feel overwhelmed and fatigued. The nurse’s response should be empathetic and supportive,

encouraging the client to share more about her situation. This could help the nurse understand the client’s support system and provide appropriate advice or resources.

Choice B rationale

While it’s important to ensure that the client isn’t overexerting herself with chores, suggesting that she shouldn’t be doing any at all might not be practical or feasible. The presence and involvement of family members can vary greatly, and while their help can be beneficial, it’s not the only factor in managing postpartum fatigue.

Choice C rationale

It’s indeed common for new mothers to feel worn out for the first few months. However, simply advising the client to rest when the baby is sleeping might not address the root cause of her fatigue. It’s also important to consider other factors such as nutrition, emotional well- being, and available support.

Choice D rationale

Telling the client that it’s normal to feel fatigued for the first few weeks might minimize her feelings. Each person’s postpartum experience is unique, and it’s crucial to validate her feelings and provide individualized care.

A. Measure the size of the scrotal sac for length and width. B. Observe the urethral opening on the surface of the penis when the newborn voids. C. Use a fingertip to palpate the inguinal canal for a weakening or indentation. D. Perform transillumination of the scrotal sac to visualize shadows of the testes.

Correct Answer is C

Explanation

Choice A rationale

Measuring the size of the scrotal sac does not verify the absence of testes.

Choice B rationale

Observing the urethral opening when the newborn voids does not verify the absence of testes.

Choice C rationale

If a testis is not readily identified, a finger sweep should be performed from the anterior iliac crest along the inguinal canal while palpating the scrotum. This is the correct technique to verify the absence of testes.

Choice D rationale

Transillumination of the scrotal sac is not the first step in verifying the absence of testes.

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A multiparous client with active herpes lesions has been admitted to the unit due to spontaneous rupture of membranes.What action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who is 3 weeks postpartum tells the nurse, “I am so tired all the time. I didn’t realize having a baby would be this challenging.”. What should the nurse’s response be?

Correct Answer is A

Explanation

During the newborn admission assessment, the nurse palpates the newborn’s scrotum and does not feel the testicles. Which assessment technique should the nurse perform next to verify the absence of testes?

Correct Answer is C

Explanation

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A multiparous client with active herpes lesions has been admitted to the unit due to spontaneous rupture of membranes.
What action should the nurse take?