During the first trimester of pregnancy, a client who was treated for genital herpes with acyclovir prior to this pregnancy tells the practical nurse (PN) that she is experiencing an episode of genital herpes. Which nursing intervention has the highest priority?

Assess her feelings about therapeutic abortions in the event the infant has been affected.

Identify current sexual partners so that they can be evaluated and treated for genital herpes if necessary.

Instruct her to avoid sexual intercourse while active, visible lesions are present.

Determine if the client has taken acyclovir for this outbreak of genital herpes.

Answer and Explanation

The Correct Answer is C

A.   Assess her feelings about therapeutic abortions in the event the infant has been affected. - While important to consider potential outcomes, immediate care involves preventing transmission and managing the current outbreak.
B.   Identify current sexual partners so that they can be evaluated and treated for genital herpes if necessary. - Contact tracing is important but not the highest priority in managing the current outbreak.
C.   Instruct her to avoid sexual intercourse while active, visible lesions are present. - This is crucial to prevent transmission of the herpes virus to the sexual partner and to reduce the risk of complications for the pregnancy.
D.   Determine if the client has taken acyclovir for this outbreak of genital herpes. - While important for understanding the treatment history, instructing the client on preventive measures has a higher priority.

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Correct Answer is A

Explanation

A. Encouraging the mother to use a one-piece pacifier is the appropriate action as it reduces the risk of choking or ingestion of small parts and is safer for the infant.
B. Observing the infant for difficulty in sucking is important, but addressing the safety of the pacifier takes precedence.
C. Informing the mother about potential dental problems associated with pacifier use might be relevant but doesn't address the immediate safety concern of the makeshift pacifier.
D. Complimenting the mother for meeting her infant's needs doesn't address the potential safety risks associated with the homemade pacifier.

A. A Write an incident report about the bruises on the infant. B. B Review the labor and delivery record for birth trauma. C. C Record the size and location of the areas in the infant's chart. D. D Notify the pediatrician of a possible bleeding problem with the infant.

Correct Answer is C

Explanation

A. Write an incident report about the bruises on the infant. - These areas might not be bruises; hence, writing an incident report without accurate information could be premature.
B. Review the labor and delivery record for birth trauma. - While important, it might not directly relate to the observed bluish-black areas.
C. Record the size and location of the areas in the infant's chart. - Documenting the observations is essential for tracking changes and informing other healthcare providers.
D. Notify the pediatrician of a possible bleeding problem with the infant. - Without further assessment, assuming a bleeding problem might be premature and unnecessarily alarming.

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During the first trimester of pregnancy, a client who was treated for genital herpes with acyclovir prior to this pregnancy tells the practical nurse (PN) that she is experiencing an episode of genital herpes. Which nursing intervention has the highest priority?

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Naxlex Comprehensive Predictor Exams

During a clinic visit, the practical nurse (PN) observes an infant sucking on a pacifier that is made from a bottle nipple and stuffed with cotton. What should the PM do?

Correct Answer is A

Explanation

During a daily assessment in the nursery, the practical nurse (PN) notices three large bluishblack areas on the back and buttocks of an African-American infant. Which action should the PN take?

Correct Answer is C

Explanation

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