A nurse is caring for a client in labor who has herpes simplex virus (HSV) with active lesions. Which of the following interventions should the nurse plan to implement to prevent the transmission of HSV to the newborn?

Apply cortisone ointment on the lesions prior to birth.

Administer erythromycin ointment in the newborn's eyes after birth.

Anticipate a scheduled cesarean birth.

Initiate IV penicillin G during the labor.

Answer and Explanation

The Correct Answer is C

A. Apply cortisone ointment on the lesions prior to birth:

Cortisone ointment is not appropriate for the treatment of herpes simplex virus (HSV) lesions. Cortisone is a steroid medication that can suppress the immune response, potentially worsening the HSV infection. Additionally, cortisone ointment does not directly treat the virus or prevent its transmission. Therefore, applying cortisone ointment on the lesions would not be effective and could even be harmful to both the mother and the newborn.

B. Administer erythromycin ointment in the newborn's eyes after birth:

Erythromycin ointment is routinely used in newborns to prevent bacterial eye infections, such as those caused by Chlamydia trachomatis or Neisseria gonorrhoeae. However, it is not effective against viruses like HSV. Therefore, while erythromycin ointment is important for preventing bacterial infections in newborns, it does not address the risk of HSV transmission from the mother to the newborn during birth.

C. Anticipate a scheduled cesarean birth:

When a pregnant person has active genital herpes lesions near the time of delivery, a scheduled cesarean section (C-section) is often recommended to reduce the risk of neonatal herpes transmission. Delivering the baby via C-section can decrease the likelihood of the newborn coming into contact with the virus in the birth canal, thereby reducing the risk of neonatal herpes infection. This intervention is specifically targeted at preventing HSV transmission to the newborn and is considered the standard of care in such situations.

D. Initiate IV penicillin G during labor:

Penicillin G is an antibiotic used to treat bacterial infections, but it is not effective against viruses like HSV. Therefore, initiating IV penicillin G during labor would not prevent the transmission of HSV to the newborn. While antibiotics may be used in certain situations during labor to prevent bacterial infections, they do not address the risk of HSV transmission and are not indicated for this purpose.

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Correct Answer is C

Explanation

A. IM in right deltoid:
The deltoid muscle is not typically used for IM injections in newborns. Additionally, the vastus lateralis muscle in the thigh is preferred over the deltoid muscle for IM injections in infants.

B. Subcutaneous in the right deltoid:
Subcutaneous administration is not the preferred route for phytonadione in newborns. Additionally, the deltoid muscle is not commonly used for subcutaneous injections in newborns.

C. IM in left vastus lateralis:
This is the correct choice. The vastus lateralis muscle in the thigh is the preferred site for IM injections in newborns due to its size and accessibility. Administering phytonadione via IM injection in the vastus lateralis muscle allows for optimal absorption of the medication.

D. Subcutaneous in the left vastus lateralis:
Subcutaneous administration is not the preferred route for phytonadione in newborns. Additionally, the vastus lateralis muscle is typically used for IM injections rather than subcutaneous injections in infants.

A. “I should avoid breastfeeding for 2 weeks following the immunization." B. "I should avoid becoming pregnant for at least 1 month following the immunization." C. "I will report joint pain that develops after the immunization to my provider immediately." D. "I will receive a series of three immunizations and each one will be a month apart."

Correct Answer is B

Explanation

A. "I should avoid breastfeeding for 2 weeks following the immunization."

This statement is incorrect. There is no need to avoid breastfeeding after receiving the rubella vaccine. Breastfeeding is safe and not contraindicated following immunization with the rubella vaccine. Breastfeeding can continue as usual without interruption.

B. "I should avoid becoming pregnant for at least 1 month following the immunization."

This statement is correct. Following administration of the rubella vaccine, it is recommended to avoid becoming pregnant for at least 1 month. This precaution is due to theoretical concerns about the vaccine potentially affecting the developing fetus if a woman were to become pregnant shortly after vaccination. Rubella infection during pregnancy can cause serious birth defects, so it's important to take precautions to avoid potential harm to the fetus.

C. "I will report joint pain that develops after the immunization to my provider immediately."

While joint pain can be a rare side effect of the rubella vaccine, it is not typically necessary to report it immediately unless it is severe or persistent. Mild joint pain is a common and expected side effect of some vaccines, including the rubella vaccine, and typically resolves on its own without intervention. However, if joint pain is severe or persistent, it may be appropriate to report it to a healthcare provider for further evaluation and management.

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A nurse is caring for a client in labor who has herpes simplex virus (HSV) with active lesions. Which of the following interventions should the nurse plan to implement to prevent the transmission of HSV to the newborn?

Nursing Test Bank

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Correct Answer is B

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