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.

Answer and Explanation

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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Correct Answer is B

Explanation

Choice A rationale

The fetal heartbeat is typically detectable by Doppler around 10-12 weeks, not as early as 6 weeks.

Choice B rationale

Monthly prenatal visits up to 28 weeks are standard practice for monitoring pregnancy.

Choice C rationale

A complete blood count is not performed at every prenatal visit but at specific intervals.

Choice D rationale

The blood test for neural tube defects, such as AFP, is usually done around 16-18 weeks, not 32 weeks.

A. Give glucose water after feedings. B. Instruct the client to avoid breastfeeding during treatment. C. Monitor intake and output. D. Apply lotions and ointments throughout the treatment.

Correct Answer is C

Explanation

Choice A rationale

Giving glucose water after feedings is not recommended for newborns undergoing phototherapy. Breastfeeding or formula feeding should be continued to provide adequate nutrition and hydration.

Choice B rationale

Instructing the client to avoid breastfeeding during treatment is not necessary. Breastfeeding should continue to promote bonding, provide nutrition, and help with the infant's hydration and bilirubin excretion.

Choice C rationale

Monitoring intake and output is crucial for a newborn receiving phototherapy to ensure proper hydration and assess the effectiveness of the treatment in lowering bilirubin levels.

Choice D rationale

Applying lotions and ointments throughout the treatment is not recommended, as they can interfere with the effectiveness of phototherapy. The skin should be clean and dry to maximize exposure to the phototherapy light.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching routine prenatal care to a group of clients who are pregnant.Which of the following statements by a client indicates an understanding of the teaching?

Correct Answer is B

Explanation

A nurse is caring for a 2-day-old newborn who has a bilirubin level of 14 mg/dL (1 to 12 mg/dL) and is to begin phototherapy.Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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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?