45. A client, who is 27 years old, gravida 1, para 0, presents to a labor and delivery unit in active labor at 38 weeks' gestation. During the initial vaginal examination, a nurse notes a papular lesion on her left labia minora. Which action should the nurse take first?
. Document the finding.
. Continue routine labor care as ordered by the physician.
. Prepare the client for a cesarean section.
. Report the finding to the physician.
Test-Taking Tip
An unidentified lesion in the vaginal area should be reported to the physician as soon as possible to avoid possible transmission of herpes. Note that only one option has "report to the physician."
Content Area: Maternity, Intrapartum; Integrated Process: Nursing Process, Implementation; Cognitive Level: Analysis; Client Need/Subneed: Safe and Effective Care Environment/Safety and Infection Control/Standard/Transmission-based/Other Precautions
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Answer 1 is incorrect because documenting the finding is not the first action to take when a client with active herpes is in active labor and needs a cesarean section. Answer 2 is incorrect because a papular lesion is consistent with genital herpes, and needs to be reported to the physician. Answer 3 is incorrect because the physician needs to be informed and the lesion should be evaluated to determine if it is herpes before proceeding with any other procedure. Active genital herpes requires a cesarean delivery, but the physician needs to make a final decision. Preparing her for a cesarean before the physician evaluates the client is not appropriate. Answer 4 is correct because a papular lesion is consistent with genital herpes and needs to be reported to the physician first before proceeding with any other assessment or treatment.