A nurse is assisting with the care of a client who is in labor with ruptured membranes and has herpes simplex virus with active lesions.
Which of the following actions should the nurse take?
Begin an amnioinfusion for the client.
Prepare the client for a cesarean birth.
Administer ampicillin IV to the client.
Initiate an oxytocin infusion for the client.
The Correct Answer is B
Prepare the client for a cesarean birth.
This is because the client has herpes simplex virus with active lesions, which can be transmitted to the newborn during vaginal delivery and cause serious complications such as neonatal herpes infection. A cesarean birth can prevent this transmission and protect the newborn’s health.
Choice A is wrong because an amnioinfusion is a procedure that involves infusing fluid into the amniotic cavity to increase the volume of amniotic fluid and reduce cord compression.
It is not indicated for a client with herpes simplex virus with active lesions.
Choice C is wrong because ampicillin is an antibiotic that is used to treat bacterial infections, not viral infections such as herpes simplex virus.
Ampicillin will not prevent the transmission of herpes simplex virus to the newborn.
Choice D is wrong because oxytocin is a hormone that stimulates uterine contractions and can be used to augment or induce labor.
It is not indicated for a client with herpes simplex virus with active lesions, as it can increase the risk of transmission to the newborn by prolonging the exposure to infected genital secretions.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The nurse should instruct the client to avoid bananas because they are one of the foods that can cause a cross-reaction with latex allergy. This means that people who are allergic to latex may also have an allergic reaction to bananas because they contain similar proteins.
Choice A is wrong because wheat is not a latex cross-reactive food.
Choice B is wrong because strawberries are a low or undetermined cross- reactive food.
Choice C is wrong because peanuts are a low or undetermined cross-reactive food.
Some other foods that the nurse should instruct the client to avoid are avocado, kiwi, chestnut, papaya, and potato. These foods have a high or moderate association with latex cross-reactions. The client should also be careful with other fruits and vegetables that may contain similar proteins to latex.
Correct Answer is C
Explanation
Verapamil is a calcium channel blocker that can lower the heart rate and blood pressure. A normal pulse rate for adults is between 60 and 100 beats per minute. A pulse rate of 48/min is too low and indicates bradycardia, which can cause dizziness, fainting, or cardiac arrest. Verapamil should not be given to patients with bradycardia or heart block.
Choice A is wrong because blood pressure 170/82 mm Hg is high and verapamil can help lower it. A normal blood pressure for adults is less than 120/80 mm Hg.
Choice B is wrong because respiratory rate 18/min is normal and verapamil does not affect it. A normal respiratory rate for adults is between 12 and 20 breaths per minute.
Choice D is wrong because potassium 4 mEq/L is normal and verapamil does not affect it. A normal potassium level for adults is between 3.5 and 5.0 mEq/L.
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