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

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale
Premature rupture of membranes is a condition that can occur during pregnancy, but it is not directly linked to uterine atony or heavy lochia after delivery.
Choice B rationale
Delivery of an intact placenta within 30 minutes of the birth of the infant is a normal occurrence and would not contribute to uterine atony or heavy lochia.
Choice C rationale
Multigravida status, or having been pregnant more than once, can contribute to uterine atony. The uterus may not contract effectively after multiple pregnancies, leading to heavy lochia.
Choice D rationale
While a history of sexually transmitted infections can impact overall reproductive health, it is not directly linked to uterine atony or heavy lochia after delivery.

A. Kernicterus. B. Severe cardiac anomaly. C. Respiratory distress syndrome. D. Hydrops fetalis.

Correct Answer is D

Explanation

Choice A rationale
Kernicterus is a rare type of brain damage that occurs in a newborn with severe jaundice. It happens when a substance in the blood, bilirubin, builds up to very high levels and spreads into the brain tissues. This condition can cause athetoid cerebral palsy and hearing loss. Kernicterus also causes problems with vision and teeth and sometimes can cause intellectual disabilities. However, the symptoms provided do not align with this condition.
Choice B rationale
A severe cardiac anomaly could cause heart failure and respiratory distress, but it would not explain the positive Coomb’s test, high bilirubin levels, severe anemia, jaundice, and generalized edema.
Choice C rationale
Respiratory distress syndrome (RDS) is a common problem in premature babies. It causes babies to need extra oxygen and help with breathing. RDS occurs most often in babies born before the 28th week of pregnancy and can be a problem for babies born before 37 weeks of pregnancy. It’s caused by a lack of a slippery substance called surfactant, which helps the lungs inflate with air and keeps them from collapsing. However, the symptoms provided do not align with this condition.
Choice D rationale
Hydrops fetalis is a severe, life-threatening problem of severe edema (swelling) in the fetus and newborn. It is also called hydrops. There are two types of hydrops fetalis: immune and nonimmune. Immune hydrops fetalis is a complication of a severe form of Rh incompatibility, which can be prevented. Nonimmune hydrops fetalis occurs as a result of other diseases, such as infections, heart or lung defects, liver disease, or genetic disorders, which aligns with the symptoms provided.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The postpartum woman is experiencing heavy lochia and has required frequent fundal massage over the past 24- hour period. Which of the following factors may have contributed to the uterine atony?

Correct Answer is C

Explanation

Correct Answer is D

Explanation

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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?