A nurse is assessing a client who is in labor.
Which of the following findings should the nurse expect?

Choice A rationale

Droplet precautions are implemented for pathogens transmitted via large respiratory droplets, such as influenza or meningococcal disease. Herpes simplex virus is typically transmitted through direct contact with lesions or secretions, not primarily through airborne droplets. Therefore, instituting droplet precautions would not be the most scientifically appropriate measure for preventing HSV transmission in this context.

Choice B rationale

Ceftriaxone sodium is a broad-spectrum cephalosporin antibiotic used to treat bacterial infections, such as gonorrhea or bacterial meningitis. Herpes simplex virus is a viral infection, and antibiotics are ineffective against viruses. Administering ceftriaxone would not address the underlying viral etiology of the newborn's exposure to HSV.

Choice C rationale

Bottle-feeding the newborn is not a primary intervention to prevent transmission of HSV from a mother with active genital herpes to a newborn. HSV is transmitted through direct contact during passage through the birth canal. Breastfeeding is generally considered safe for mothers with HSV unless there are active lesions on the breast.

Choice D rationale

Obtaining surface cultures from the newborn is a crucial diagnostic step to confirm the presence of HSV infection in a neonate exposed during birth. This allows for timely initiation of antiviral therapy, such as acyclovir, which is essential to prevent systemic dissemination and severe complications like encephalitis, which can be life-threatening in newborns.

Based on the 0715 assessment findings, the nurse identifies that the client is at greatest risk for developing postpartum hemorrhage and urinary tract infection.

Rationale for correct answers
Postpartum hemorrhage risk is indicated by a boggy fundus located 2 fingerbreadths above the umbilicus and deviated to the right, signifying uterine atony and bladder distention. Uterine atony causes inadequate contraction, increasing bleeding risk. Normal fundal position is firm, midline, at or below the umbilicus. The client’s saturated perineal pad confirms excessive bleeding. Urinary tract infection risk is suggested by urinary retention signs (urge to urinate but only voiding 50 mL) and straining, increasing bacterial colonization risk. Blood-tinged urine further supports urinary tract irritation or infection. Normal urine output in adults is approximately 0.5 mL/kg/hr; this client’s low output suggests retention.

Rationale for incorrect answers
Postpartum infection (B) and endometritis (C) are possible but less immediately likely; WBC is normal at 7,500/mm³ and temperature is only mildly elevated (37.7°C). Uterine inversion (D) is a rare, acute emergency with a prolapsed uterus, not described here. Endometritis (B) typically presents with fever, uterine tenderness, and elevated WBC, absent here.

Rationale for incorrect answers
Postpartum infection (A) and endometritis (B) again are unlikely given stable WBC and low-grade temperature. Uterine inversion (D) does not correlate with the clinical presentation of a boggy, displaced fundus and urinary retention. The urinary tract infection (C) is most consistent with symptoms of retention, pain, and bloody urine.

Take home points

• Boggy, displaced fundus with heavy bleeding signals uterine atony and postpartum hemorrhage risk.
• Urinary retention increases risk for urinary tract infection post-cesarean birth.
• Mild temperature elevation and normal WBC do not confirm infection but warrant monitoring.
• Differentiating uterine atony from uterine inversion and infection is critical for timely intervention.