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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
During labor, the body experiences physiological stress, which typically causes an increase, not a decrease, in white blood cell (WBC) count. This increase is a normal response to stress.
Choice B rationale
Blood glucose levels can decrease during labor due to the energy expenditure and physiological demands of the process. This is why it is important to monitor glucose levels and provide necessary interventions if hypoglycemia occurs.
Choice C rationale
The respiratory rate generally increases during labor to meet the increased oxygen demands of the body. A decrease in respiratory rate is not expected during this time.
Choice D rationale
Body temperature may increase slightly during labor due to the physical exertion and metabolic activity involved. A decrease in temperature is not a typical finding during labor. .
Correct Answer is A
Explanation
Choice A rationale
Terbutaline can cause tachycardia. A heart rate of 132/min is significantly higher than normal and could indicate severe cardiovascular effects.
Choice B rationale
While headaches can occur with terbutaline, they are generally not life-threatening and don't require immediate intervention compared to tachycardia.
Choice C rationale
Nasal congestion is a minor side effect and not a priority compared to a significantly elevated heart rate.
Choice D rationale
Tremors are common with terbutaline use, but they are usually not as concerning as a significantly elevated heart rate.
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