The nurse is documenting assessments of pregnant clients in the antepartum unit. Which client's assessment findings are most important to report to the health care provider?

Question

Quizplus · Accepted Answer

11ecbb05_cbf6_4e9d_b433_333d27519b3e_MD0009_00 Painful genital lesions can be indicative of an outbreak of genital herpes simplex virus (HSV) and are a priority assessment finding to report to the health care provider. Herpes in pregnant women can be transmitted to the infant in utero (congenital HSV), perinatally, or postnatally as a result of direct contact with virus particles shed from the infected vulva, vagina, cervix, or perineum. Neonatal HSV infection has serious morbidity (eg, permanent neurologic sequelae) and mortality. Immediate antiviral therapy (eg, acyclovir) should be initiated to treat the active infection. Vaginal birth is not recommended in the presence of active lesions; cesarean birth helps reduce the risk of transmission to the newborn (Option C). (Option A) A systolic murmur (swooshing sound heard during S1) is a common finding in pregnancy. It results from increased total body volume (flow murmur) and usually resolves after birth. No further intervention is necessary if the client is asymptomatic. (Option B) Edema of the lower extremities is common in the third trimester, especially after long periods of standing. Pressure from the enlarged uterus slows venous return, contributing to dependent edema, which usually improves with rest and elevation of the legs. (Option D) Vaginal discharge increases at the end of pregnancy and may become mucoid and blood-tinged (pink/brownish) in the days preceding labor. This assessment finding may be a sign of approaching labor in this client at term gestation (39 weeks), but it is not the priority to report to the health care provider. Educational objective: Painful genital lesions during pregnancy are a priority assessment finding to report to the health care provider. Active herpes lesions that are present at the onset of labor indicate the need for cesarean birth.

The Nurse Is Documenting Assessments of Pregnant Clients in the Antepartum