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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Contact information for a community mental health center. A community mental health center can provide ongoing outpatient care and support services for a client who has schizophrenia after discharge from an inpatient unit. A community mental health center can also help the client access other resources such as medication, housing, and vocational training.
Choice B is wrong because a list of primary prevention activities is not relevant for a client who already has schizophrenia. Primary prevention aims to prevent the occurrence of a disease or disorder in the first place.
Choice C is wrong because contact information for enrollment in a 12-step program is not appropriate for a client who has schizophrenia unless they also have a substance use disorder. A 12-step program is a self-help group that follows a set of principles to achieve and maintain sobriety.
Choice D is wrong because a referral for respite care services is not necessary for a client who has schizophrenia unless they also have a caregiver who needs temporary relief from their caregiving duties. Respite care services provide short-term care for clients who are dependent on others for their daily needs.
Correct Answer is B
Explanation
The nurse should begin discharge planning upon the client’s admission. This is because discharge planning is a key aspect of effective care that reduces the length of stay, emergency readmissions and pressure on hospital beds. Discharge planning involves considering what support might be required by the client in the community, referring the client to these services, and liaising with these services to manage the client’s discharge.
Choice A is wrong because the nurse is not responsible for providing a written prescription for a client home care referral. This is the role of the provider or another authorised prescriber.
Choice C is wrong because a home hazard appraisal does not include an assessment of the client’s financial resources. A home hazard appraisal is an evaluation of the safety and accessibility of the client’s home environment.
Choice D is wrong because a medication reconciliation is not required 24 hours prior to the client’s discharge. A medication reconciliation is a process of comparing the medications a client is taking with those prescribed for them to avoid errors or discrepancies. A medication reconciliation should be done at every transition of care, including admission, transfer and discharge.
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