Which of the following actions should a nurse take for a newborn who has herpes simplex virus as a result of in utero transmission?

Choice A reason: A front-facing car seat is unsafe for newborns, especially premature ones, due to weak neck muscles and higher crash injury risk. Rear-facing seats support the head and spine, reducing impact forces. Premature infants require rear-facing car seats in the back seat to minimize trauma, per pediatric safety guidelines.

Choice B reason: Positioning the retainer clip at the abdomen is incorrect, as it should be at chest level (axilla) to secure the harness and prevent injury. Abdominal placement risks organ damage during a crash, as premature infants have fragile physiology. Proper clip placement ensures optimal restraint, aligning with car seat safety principles.

Choice C reason: Securing a car seat at a 60-degree angle is excessive; the recommended angle is 30-45 degrees to support airway patency in premature infants. Steeper angles risk head slumping, obstructing breathing due to immature neck control. Correct angle ensures respiratory safety, critical for preterm infants with underdeveloped respiratory systems.

Choice D reason: A car seat test is essential for premature newborns to assess tolerance for upright positioning, as they risk oxygen desaturation or apnea due to immature respiratory control. The test monitors vital signs for 90-120 minutes, ensuring safe vehicle transport. This intervention prevents cardiorespiratory events, aligning with neonatal discharge protocols.

Choice A reason: Administering an IV bolus of lactated Ringer’s is not indicated for preeclampsia without severe features, as fluid overload can exacerbate hypertension or pulmonary edema. P ओपेक्शिया involves endothelial dysfunction, and excessive fluids may worsen vascular leakage. Blood pressure and symptom monitoring are prioritized over fluid administration in non-severe cases.

Choice B reason: Misoprostol is used for labor induction or postpartum hemorrhage, not preeclampsia management. Preeclampsia requires blood pressure control and seizure prophylaxis, not cervical ripening agents. Misoprostol’s prostaglandin effects are irrelevant to preeclampsia’s pathophysiology, which involves vasoconstriction and endothelial damage, making this medication inappropriate for the condition’s treatment.

Choice C reason: Assessing blood pressure twice daily is insufficient for preeclampsia, even without severe features, as it requires frequent monitoring (every 4-6 hours) to detect progression to severe hypertension. Preeclampsia can rapidly worsen due to vascular instability, and infrequent checks risk missing critical changes, compromising maternal and fetal safety.

Choice D reason: Assessing for edema is essential in preeclampsia, as it reflects vascular leakage from endothelial dysfunction. Edema, especially in the face or hands, signals worsening disease, necessitating closer monitoring or intervention. This assessment tracks fluid retention, a key pathophysiological feature of preeclampsia, aiding in early detection of progression to severe features.