The labor nurse is admitting a patient in active labor with a history of genital herpes.
On assessment, 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 the patient for a cesarean delivery
Take a culture of the lesions to verify the involved organism
Ask the patient if she has had unprotected sex since her outbreak
Use internal electronic fetal surveillance to determine a baseline fetal heart rate
The Correct Answer is A
Choice A rationale
If a patient in active labor has a recent outbreak of genital herpes with verified lesions on the perineum, the nurse should prepare the patient for a cesarean delivery. This is to prevent transmission of the herpes virus to the baby during delivery.
Choice B rationale
While taking a culture of the lesions could help verify the involved organism, it would not change the immediate plan of care for this patient. The presence of active lesions necessitates a cesarean delivery regardless of the specific strain of the virus.
Choice C rationale
Asking the patient if she has had unprotected sex since her outbreak would not directly impact the plan of care in this situation. The primary concern is preventing transmission of the virus to the baby during delivery.
Choice D rationale
Using internal electronic fetal surveillance to determine a baseline fetal heart rate is generally avoided in patients with active genital herpes lesions, as this could potentially increase the risk of transmitting the virus to the baby.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Giving an infant with a positive PKU test a high protein diet is not recommended. This is because phenylalanine, which cannot be broken down by individuals with PKU, is found in high-protein foods.
Choice B rationale
Parents of infants with a positive PKU test should provide the infant with a diet containing small amounts of phenylalanine. This is because while phenylalanine is harmful in large amounts to individuals with PKU, it is still an essential amino acid that the body needs in small amounts.
Choice C rationale
Early introduction of cow’s milk is not necessary before 1 year of age for infants with a positive PKU test. In fact, cow’s milk is high in phenylalanine and should be avoided.
Choice D rationale
Following up with a pediatric cardiologist is not specifically related to the dietary management of PKU. While regular medical supervision is important for children with PKU, it does not necessarily have to be with a cardiologist.
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.
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