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?

Choice A rationale

Feeding from only one breast can lead to engorgement and a decrease in milk supply in the affected breast. It is important to continue breastfeeding from both breasts, even if one is infected.

Choice B rationale

Discarding milk is not necessary and can lead to a decrease in milk supply. The infection does not harm the baby, and breastfeeding helps to drain the breast and clear the infection.

Choice C rationale

Moist heat can help to increase blood flow and promote healing in the affected breast. Applying warm compresses or taking warm showers can help to reduce pain and inflammation associated with mastitis.

Choice D rationale

While staying hydrated is important for overall health, there is no specific requirement to drink at least 1500 milliliters of fluid per day for mastitis. Adequate fluid intake should be maintained, but there is no direct correlation with resolving the infection.

Reproductive System

1. Assist with breastfeeding techniques to ensure proper latch: This is correct because the client is breastfeeding and proper latch is crucial for effective breastfeeding and preventing nipple pain or damage.
2. Educate the client on signs of postpartum depression and provide resources for support: This is correct because postpartum depression can occur, and educating the client about its signs and providing resources for support is essential.
3. Administer antibiotics to prevent infection at the incision site: This is incorrect because there is no indication of an infection at the episiotomy site. Administering antibiotics without signs of infection is not necessary.
4. Encourage the client to take hot baths to relieve perineal pain: This is incorrect because hot baths are not recommended postpartum due to the risk of introducing bacteria to the perineal area. Instead, sitz baths with warm water are typically recommended.

Circulatory System

1. Monitor blood pressure and heart rate regularly: This is correct because monitoring vital signs is essential postpartum to detect any potential complications such as hypertension or postpartum hemorrhage.
2. Encourage early ambulation to prevent thromboembolism: This is correct because early ambulation helps prevent the formation of blood clots, which is a risk postpartum.
3. Administer diuretics to reduce fluid retention: This is incorrect because there is no indication that the client has excessive fluid retention. Diuretics are not typically used postpartum unless there is a specific medical indication.
4. Restrict fluid intake to prevent hypertension: This is incorrect because restricting fluid intake is not an appropriate intervention postpartum. Adequate hydration is important for recovery and breastfeeding.

Respiratory System

1. Encourage deep breathing exercises and use of an incentive spirometer: This is correct because these exercises help prevent respiratory complications such as atelectasis and promote lung expansion.
2. Monitor oxygen saturation levels and respiratory rate: This is correct because monitoring respiratory status is essential to ensure the client is not experiencing any respiratory distress.
3. Administer bronchodilators to improve lung function: This is incorrect because there is no indication that the client has respiratory issues that require bronchodilators.
4. Place the client in a supine position to promote lung expansion: This is incorrect because the supine position does not promote lung expansion effectively. Instead, the client should be positioned with the head of the bed elevated.