The labor nurse is admitting a patient in active labor who has a history of genital herpes. The patient reports a recent outbreak, and the nurse verifies lesions on the perineum.
What action should the nurse take in anticipating the plan of care for this patient?
Prepare for a vaginal delivery:.
Administer antiviral medication.
Prepare for a cesarean delivery.
Discharge the patient:
The Correct Answer is C
Choice A (Prepare for a vaginal delivery) is incorrect. Vaginal delivery is generally not recommended for women with active genital herpes lesions present during labor due to the high risk of transmitting the virus to the newborn. This risk is especially high when the mother experiences a primary infection (first outbreak) during the third trimester or has visible lesions at the time of delivery.
Choice B (Administer antiviral medication) is partially correct. While antiviral medications can be helpful in managing and potentially shortening outbreaks, they alone are not enough to prevent transmission during delivery. Antiviral medication can be used in combination with cesarean delivery to further reduce the risk of transmission.
Choice C (Prepare for a cesarean delivery) is correct. A cesarean delivery is the preferred method of delivery for women with active genital herpes lesions present during labor because it significantly reduces the risk of the virus being transmitted to the newborn. This risk can be as high as 50% during vaginal delivery with active lesions, while the risk with cesarean delivery is significantly lower, typically around 1% or less.
Choice D (Discharge the patient) is incorrect. Discharging a patient in active labor with active genital herpes lesions is not a safe or appropriate course of action. The patient needs to be carefully monitored and managed in a healthcare setting to minimize the risk of transmission to the newborn and ensure the safety of both mother and baby.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Hot flashes are typically associated with menopause, not endometriosis. They occur due to changes in hormone levels, particularly a decrease in estrogen.
Choice B rationale
Dyspareunia, or painful intercourse, is a common symptom of endometriosis. The condition can cause adhesions and lesions in and around the pelvic organs, leading to pain during sexual activity.
Choice C rationale
Fluid retention is not specifically associated with endometriosis. It can occur due to a variety of conditions, including hormonal changes, dietary factors, and certain medications.
Choice D rationale
Fever is not a typical symptom of endometriosis. It’s more commonly associated with infections or inflammatory conditions.
Correct Answer is ["B","C","D"]
Explanation
Choice A rationale
Breastfeeding every 2 hours is actually recommended for newborns and is not a contributing factor to mastitis.
Choice B rationale
Substituting breastfeeding sessions with formula feeding can contribute to mastitis. This is because the milk that is not removed from the breast can lead to engorgement and blocked ducts, which can result in infection.
Choice C rationale
Blisters and cracks on the nipples can allow bacteria to enter the breast tissue, leading to infection and mastitis.
Choice D rationale
Alternating breastfeeding positions can help ensure that the breasts are emptied completely during each feeding, which can help prevent mastitis.
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