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?

1. A nurse is assessing a postpartum client who delivered vaginally 8 hr ago.

Exhibit 1

Nurses' Notes

0700:

Breasts soft, nipples intact. Uterus palpated firm, midline, and at level of umbilicus. Moderate amount of lochia rubra. Episiotomy site well approximated with mild edema and ecchymosis. Client reports pain as 2 on a scale of 0 to 10. Able to void spontaneously; no bladder distention. Deep tendon reflexes 1+. Peripheral edema 2+ in bilateral lower extremities.

1100:

Breasts soft, nipples intact. Uterus palpated soft with lateral deviation and 1 cm above the umbilicus. Large amount of lochia rubra. Episiotomy site well approximated with mild edema and ecchymosis. Client reports pain as 3 on a scale of 0 to 10. Deep tendon reflexes 1+ Peripheral edema 2+ in bilateral lower extremities.

Exhibit 2

0700:

Temperature 36.2" C (97.2" F) Pulse rate 80/min

Respiratory rate 16/min

Blood pressure 136/82 mm Hg

Pulse oximetry 99%

1100:

Temperature 37.2° C (99.0° F)

Pulse rate 85/min

Respiratory rate 18/min

Blood pressure 136/86 mm Hg

Pulse oximetry 100%

Select the 3 findings that require immediate follow-up.

1. A nurse is caring for a newborn immediately following birth.

Exhibit 1

Medical History

Vacuum-assisted vaginal birth

Maternal history of positive group B streptococcus 8-hemolytic Mother received two doses of ampicillin IV bolus during labor

Exhibit 2

Vital Signs

Apgar:

Heart rate 96/min

Weak cry

Muscle tone: some flexion

Reflex: grimace

Color: acrocyanosis

Axillary temperature 36.9° C (98.5° F)

Exhibit 3

Medications

Erythromycin ophthalmic ointment once 1 to 2 hr after birth Hepatitis B vaccine 10 mcg/0.5 mL IM once within 24 hr after birth

Phytonadione 1 mg IM once 1 to 2 hr after birth

Exhibit 4

Laboratory Findings

WBC count 15,000mm (9,000 to 30,000/mm)

Hgb 19 g/dl (15 to 24 g/dL)

HCt 57% (44% to 70%)

Blood glucose 44 mg/dl (40 to 60 mg/dL)

The nurse is assessing the newborn 24 hr later. How should the nurse interpret the findings?

For each finding, click to specify whether the finding is unrelated to the diagnosis, an indication that the client's condition is improving, or indication that the client's condition is worsening

A nurse on a labor and delivery unit is providing teaching to a client who plans to use hypnosis to control labor pain. Which of the following Information should the nurse Include?

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?

A nurse is caring for a client who is in the second stage of labor and is experiencing a shoulder dystocia. The provider instructs the nurse to perform the McRoberts maneuver. Which of the following actions should the nurse take?

A nurse is providing teaching to a postpartum client who has a prescription for a rubella immunization. Which of the following client statements Indicates understanding of the teaching?

A nurse is planning care for a client who is 12 hr postpartum and has a third-degree perineal laceration. Which of the following interventions should the nurse include in the plan?

A nurse is caring for a client who has a placenta previa. Which of the following findings should the nurse expect?

A nurse is assessing the newborn of a client who reports methadone use during pregnancy. The nurse should expect the newborn to exhibit which of the following manifestations?

A postpartum nurse is caring for a client and their newborn. Which of the following observations should indicate to the nurse that the client is in the taking-in phase of maternal role attainment?