A nurse is planning care for a newborn who was exposed to active genital herpes simplex virus (HSV) during birth.
Which of the following nursing actions should the nurse anticipate?
Institute droplet precautions.
Administer ceftriaxone sodium.
Inform the client they should bottlefeed the newborn.
Obtain surface cultures from the newborn.
The Correct Answer is D
Choice A rationale
Instituting droplet precautions is not necessary for herpes simplex virus (HSV). HSV is primarily transmitted through direct contact with infected body fluids or lesions, not through respiratory droplets.
Choice B rationale
Administering ceftriaxone sodium is not appropriate for HSV. Ceftriaxone is an antibiotic used to treat bacterial infections, whereas HSV is a viral infection and requires antiviral treatment.
Choice C rationale
Informing the client they should bottlefeed the newborn is not necessary. Mothers with HSV can breastfeed as long as there are no herpetic lesions on the breast. Proper hand hygiene and preventive measures should be taken to avoid transmission.
Choice D rationale
Obtaining surface cultures from the newborn is the appropriate action. This helps in detecting the presence of HSV and initiating antiviral treatment if necessary. Early detection and treatment are crucial in preventing severe complications associated with neonatal HSV infection.
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Related Questions
Correct Answer is C
Explanation
Choice A rationale
Cooling the newborn’s heel would constrict blood vessels and make it more difficult to obtain a blood sample. Warming the heel is the preferred method to increase blood flow.
Choice B rationale
Puncturing the center of the newborn’s heel is not recommended as it could cause more pain and potential injury to the bone. The puncture should be done on the outer edges of the heel.
Choice C rationale
Cleansing the puncture site with alcohol gauze is essential to reduce the risk of infection and ensure that the sample is not contaminated.
Choice D rationale
Administering vitamin K before each blood draw is unnecessary. Vitamin K is typically given as a one-time dose to prevent bleeding issues, not related to blood draw procedures.
Correct Answer is B
Explanation
Choice A rationale
Elevated BUN levels (25 mg/dL) can indicate kidney dysfunction, dehydration, or high protein intake. However, it’s not directly related to a prenatal complication, though it still requires monitoring.
Choice B rationale
Hemoglobin (Hgb) of 10.2 mg/dL is below the normal range (11 to 16 mg/dL) and can indicate anemia. During pregnancy, anemia can lead to serious complications such as preterm birth and low birth weight, making this result significant.
Choice C rationale
A fasting blood glucose level of 70 mg/dL falls within the normal range (70 to 110 mg/dL) and does not indicate a complication. Thus, it is not concerning in the context of prenatal complications.
Choice D rationale
Hematocrit (Hct) of 32% is slightly below the normal range (33 to 47%), which can be common in pregnancy due to increased plasma volume. While monitoring is required, it’s not as critical as anemia.
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