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 C
Explanation
Choice A rationale
Theca-lutein cysts are not commonly found in females of reproductive age. They are often associated with conditions that cause high levels of human chorionic gonadotropin, such as molar pregnancies.
Choice B rationale
Corpus luteum cysts can occur in women of reproductive age, but they do not typically regress with the menstrual cycle. Instead, they usually resolve after a few weeks if pregnancy does not occur.
Choice C rationale
Follicular cysts are commonly found in females of reproductive age and often regress with the menstrual cycle. They form when the follicle that normally releases an egg does not open to release the egg.
Choice D rationale
Polycystic ovarian syndrome is a condition characterized by multiple small cysts in the ovaries, but it does not typically cause cysts that regress with the menstrual cycle.
Correct Answer is C
Explanation
Choice A rationale
In infants with asymmetric intrauterine growth restriction (IUGR), not all body parts appear proportionate. Typically, the head is disproportionately larger compared to the rest of the body.
Choice B rationale
While the extremities can be smaller in infants with IUGR, this is not specific to asymmetric IUGR910.
Choice C rationale
In asymmetric IUGR, the head seems large compared with the rest of the body. This is because the body slows its growth to allow the brain to continue growing.
Choice D rationale
One side of the body appearing slightly smaller than the other is not a typical characteristic of asymmetric IUGR910.
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