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 C

Explanation

Choice A rationale

While notifying the healthcare provider of the assessment findings is important, it would not be the first action to take. The nurse should first gather more information about the client’s condition.

Choice B rationale

Obtaining a STAT hemoglobin and hematocrit would not be the first action to take. These tests could provide information about the client’s blood volume and potential for anemia, but they would not directly address the client’s complaint of a severe headache.

Choice C rationale

Determining if the client received anesthesia during delivery is the correct first action. A severe headache in the postpartum period can be a sign of a post-dural puncture headache, which can occur as a complication of spinal or epidural anesthesia.

Choice D rationale

Assigning a practical nurse (PN) to reassess the client’s vital signs would not be the first action to take. While ongoing monitoring of the client’s vital signs is important, the nurse should first investigate the potential cause of the client’s severe headache.

A. Encourage the mother to breastfeed more frequently. B. Monitor the neonate’s stool and urine output for the last 24 hours. C. Reassure the mother that this is a normal weight loss. D. After verifying the weight’s accuracy, inform the healthcare provider.

Correct Answer is C

Explanation

Choice A rationale

While breastfeeding more frequently can be beneficial for the mother-infant bonding and milk production, it does not directly address the infant’s weight loss.

Choice B rationale

Monitoring the neonate’s stool and urine output for the last 24 hours can provide information about the infant’s hydration status. However, it does not directly address the concern of weight loss.

Choice C rationale

It is normal for newborns to lose some weight in the first few days after birth. This is often due to the loss of excess fluid. A weight loss of up to 10% of the birth weight is generally considered normal in the first week.

Choice D rationale

While it’s important to verify the accuracy of the weight measurement, informing the healthcare provider is not the immediate action required if the weight loss is within the normal range.

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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?

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Naxlex Comprehensive Predictor Exams

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Explanation

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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?