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 A
Explanation
Choice A rationale
Trichomoniasis is a sexually transmitted infection that can cause a frothy, yellow-green vaginal discharge. Other symptoms can include genital itching, burning during urination, and a strong fish-like odor, especially after sex.
Choice B rationale
Bacterial vaginosis is a common vaginal infection that can cause a thin, white or gray vaginal discharge with a fishy smell. However, the discharge is typically not described as frothy or yellow-green.
Choice C rationale
Chlamydia is a sexually transmitted infection that can cause a variety of symptoms, but a frothy, yellow-green discharge is not typically one of them. Symptoms of chlamydia in women can include abnormal vaginal discharge, but it is often described as mucopurulent (resembling mucus or pus) rather than frothy.
Choice D rationale
Gonorrhea is a sexually transmitted infection that can cause a variety of symptoms, but a frothy, yellow-green discharge is not typically one of them. Women with gonorrhea may experience increased vaginal discharge, but it is often described as thin and watery or thick and purulent, not frothy.
Correct Answer is B
Explanation
Choice A rationale
Lying down with arms at the side is not the recommended position for a breast self-exam. The recommended positions are either standing or lying down with the arm raised.
Choice B rationale
Using the finger pads of the three middle fingers to apply pressure to the breast is a correct technique for a breast self-exam. This method allows for thorough examination of the breast tissue.
Choice C rationale
It is not correct to avoid checking under the arm if the breast feels fine. The breast tissue extends into the underarm area, so it is important to check this area as well during a breast self-exam.
Choice D rationale
Working from left to right down the breast towards the ribs is not a standard instruction for a breast self-exam. The recommended method is to use a circular, up-and-down, or wedge pattern.
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