A nurse is preparing to administer an opioid analgesic to a client who is in active labor.
Which of the following assessments should the nurse perform?

Choice A rationale

Droplet precautions are implemented for pathogens transmitted via large respiratory droplets, such as influenza or meningococcal disease. Herpes simplex virus is typically transmitted through direct contact with lesions or secretions, not primarily through airborne droplets. Therefore, instituting droplet precautions would not be the most scientifically appropriate measure for preventing HSV transmission in this context.

Choice B rationale

Ceftriaxone sodium is a broad-spectrum cephalosporin antibiotic used to treat bacterial infections, such as gonorrhea or bacterial meningitis. Herpes simplex virus is a viral infection, and antibiotics are ineffective against viruses. Administering ceftriaxone would not address the underlying viral etiology of the newborn's exposure to HSV.

Choice C rationale

Bottle-feeding the newborn is not a primary intervention to prevent transmission of HSV from a mother with active genital herpes to a newborn. HSV is transmitted through direct contact during passage through the birth canal. Breastfeeding is generally considered safe for mothers with HSV unless there are active lesions on the breast.

Choice D rationale

Obtaining surface cultures from the newborn is a crucial diagnostic step to confirm the presence of HSV infection in a neonate exposed during birth. This allows for timely initiation of antiviral therapy, such as acyclovir, which is essential to prevent systemic dissemination and severe complications like encephalitis, which can be life-threatening in newborns.

Choice A rationale

A shrill or high-pitched cry in a newborn can be a symptom of neurological irritability, which is often associated with hypoglycemia. Hypoglycemia in newborns can lead to central nervous system dysfunction due to insufficient glucose supply to the brain, manifesting as altered cry patterns.

Choice B rationale

Weak peripheral pulses can indicate poor cardiac output or peripheral vasoconstriction, which might be associated with conditions like congenital heart defects or hypovolemia. While significant hypoglycemia can impact cardiovascular function, weak pulses are not the primary or most specific indicator.

Choice C rationale

Yellowish skin, or jaundice, is caused by elevated bilirubin levels in the blood, often due to physiological immaturity of the liver or increased red blood cell breakdown. While jaundice can be a symptom of various newborn issues, it is not a direct or common sign of hypoglycemia.

Choice D rationale

Hypotonia, or decreased muscle tone, can be a symptom of various neurological issues, including severe hypoglycemia, but also other conditions like birth trauma, sepsis, or genetic disorders. While it can be present with hypoglycemia, a shrill cry is a more specific and earlier indicator.