Nokea
The nurse is working in the labor and delivery suite when a client with active herpes simplex virus type 2 (HSV-2) appears in active labor. Which adjustment in the plan of care will the nurse prepare for?
- A. Administer an intravenous antibiotic to the mom while in labor.
- B. Complete a full assessment of the newborn on delivery.
- C. Prepare for a cesarean section.
- D. Place an antibacterial ointment on the mother's lesions.
Correct Answer: C
Rationale: The nurse is most accurate to prepare for a cesarean section because the mother has an active lesion and does not want to transmit the virus to the newborn. Antibiotic therapy does not prevent the transmission of the infection. A full assessment is always completed on the newborn and is not an adjustment in the plan of care. Antibacterial ointment is not placed on the mother's lesions.
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During a sexual history, the client states that having had multiple sex partners. Which statement by the nurse is appropriate?
- A. You are putting yourself at risk when you have multiple sex partners.
- B. The chance of acquiring a sexually transmitted disease increases with multiple sex partners.
- C. It is hard to find a good partner these days.
- D. What do you do to prevent sexually transmitted infections?
Correct Answer: D
Rationale: The nurse must obtain the client's feedback in a nonjudgmental way to open communication. When communication is open, the nurse has the best potential to provide nursing instruction and emphasize key points. Being judgmental or introducing the nurse's opinion does not promote therapeutic communication.
The nurse is instructing a client on proper procedures to protect herself from sexually transmitted infections (STIs). Which statement, made by the client, requires correction from the nurse?
- A. If I use barrier protection, it will reduce my risk of exposure to STIs.
- B. You cannot always know everything about a person.
- C. I consider myself protected because I am on birth control pills.
- D. I refrain from sexual contact or use protection to keep myself safe.
Correct Answer: C
Rationale: The nurse is most correct to clarify that although birth control pills are effective at preventing pregnancy, they do not prevent against exposure to STIs. The other statements have no inaccurate content as can be determined at this time.
A client requesting a chlamydia test asks why it is necessary to receive a test for gonorrhea and syphilis at the same time. Which response from the nurse is the correct explanation?
- A. The symptoms of these diseases are the same, and culture tests alone can determine the disease that has infected the client.
- B. The infecting bacterium in all cases is the same, and therefore, clients have concurrent infections.
- C. The infections spread through the same medium, and therefore, clients have concurrent infections.
- D. It is not unusual for clients to have concurrent infections with more than one sexually transmitted infection (STI).
Correct Answer: D
Rationale: It is common practice to test clients for chlamydia, gonorrhea, syphilis, and HIV because it is not unusual for clients to have concurrent infections with more than one STI. For chlamydia, the causative microorganism is a bacterium named Chlamydia trachomatis. For gonorrhea, the infection is caused by a bacterium named Neisseria gonorrhoeae. The spirochete Treponema pallidum is the causative microorganism of syphilis. The symptoms of these conditions are not identical. The causative microorganisms do not spread through the same medium.
A client with syphilis did not receive treatment and has now progressed into the tertiary stage of the disorder. Which symptoms would the nurse expect the client to exhibit?
- A. Ulcated chancre, aortic valve insufficiency, lymphadenopathy
- B. Fever, malaise, sore throat
- C. Papular lesions, rash, headache
- D. Tabes dorsalis, ataxia, and Charcot's joints
Correct Answer: D
Rationale: The client with late or tertiary syphilis is noninfectious because the microorganism has invaded the central nervous system (CNS) as well as other organs of the body. Symptoms of tertiary syphilis include tabes dorsalis (a degenerative condition of the CNS that results in loss of peripheral reflexes and of vibratory and position senses), ataxia, and neuropathic joint disease, also called Charcot's joints. Symptoms of secondary syphilis include fever, malaise, rash, headache, sore throat, and lymph node enlargement. Ulcerated chancre occurs in the primary stage.
The nurse is counseling a client who has been diagnosed with two sexually transmitted infections. The client is shocked and states not knowing how this has happened. Which of the following statements is most appropriate by the nurse?
- A. Your partner could have been asymptomatic at that time.
- B. You should have asked your partner if they have any infections.
- C. Sexually transmitted infections have obvious signs of their presence.
- D. Your partner should have told you of a previous infection.
Correct Answer: A
Rationale: The nurse is most correct to support the client and provide information on how the infection could have been spread. It is true that the client's partner could have been asymptomatic during their sexual contact. The nurse should not be judgmental or accusing in nature as in the other responses.