Patient is admitted to the labor and delivery unit in active labor. During examination, the nurse notes a papular lesion on the perineum. Which initial action is most appropriate?

1. A

   Document the finding.

2. B

   Report the finding to the doctor.

3. C

   Prepare the client for a C-section.

4. D

   Continue primary care as prescribed.

Appeared in: NCL (MP) Nursing Officer - 2020

Explanation

• The presence of a perineal lesion during labor is a critical finding that requires immediate attention.
• The primary concern is the possibility of an active genital herpes (HSV) infection, which can be transmitted to the neonate during vaginal birth, leading to severe or fatal neonatal herpes.
• The nurse's priority action, based on patient safety principles, is to report this finding to the healthcare provider immediately for assessment, diagnosis, and determination of the safest mode of delivery.
• This action falls within the nurse's role of assessment and reporting and is crucial for facilitating timely medical intervention.

Why Other Options Were Wrong

• Option A: While documentation is a crucial part of nursing care, it is not the first priority when a finding indicates an immediate potential risk to the patient or fetus. Action must precede documentation in urgent situations.
• Option C: Preparing for a Cesarean section is an intervention that requires a physician's order. The nurse cannot independently make this decision. The lesion must first be assessed by the provider to determine if a C-section is necessary.
• Option D: Continuing with the current plan of care means ignoring a new and significant clinical finding. This would be considered negligent as it fails to address a potential threat to fetal well-being.

Related Visual

Clinical Relevance

• Nursing practice connection: Use the key finding related to Nursing priorities in intrapartum care to guide bedside assessment, documentation, and the next nursing action.
• This scenario emphasizes the nurse's critical role in maternal and fetal surveillance during labor. Prompt identification and reporting of abnormal findings can prevent life-threatening complications.
• Failure to report such a finding can lead to neonatal herpes, which has high rates of morbidity and mortality.
• What if? If the patient had a known history of genital herpes but no active lesions were visible upon examination, the nurse should still inform the provider. The plan of care, which may include suppressive antiviral therapy, would be confirmed, and a vaginal delivery would likely be permissible.

How to Approach the Question

• First, identify the core elements of the clinical scenario: a patient in active labor with a new, abnormal physical finding (a papular perineal lesion).
• Second, analyze the potential risk associated with the finding. A perineal lesion in labor immediately raises concern for an active infection like genital herpes (HSV), which poses a serious risk of transmission to the baby.
• Third, evaluate the options based on the principles of patient safety and the nursing scope of practice. The priority is always to mitigate immediate harm.
• Fourth, determine the most appropriate initial action. Reporting the finding to the healthcare provider is the only option that addresses the immediate risk and allows for a timely medical evaluation and decision, which is paramount for fetal safety.
• Eliminate options that are out of scope (preparing for C-section without an order), delayed (documenting before reporting), or negligent (ignoring the finding).

Concept Tested & Keywords

• Concept Tested: Nursing priorities in intrapartum care
• Stem keywords: active labor, papular lesion, perineum, initial action
• Lead-in keywords: most appropriate
• Clinical cues: The presence of a new lesion during the active phase of labor is a red flag for potential infection that could affect the fetus.

Question ID

QslGMPuX2WXDQtLb5SKtQl

Copy ID

Reference Book

E6 Nelson Textbook of Pediatrics(2024) — Volume 1 p. 2004-2006

E6 Medicine Davidson Principles Practice 24e p. 356-358

E6 Medicine Harrison 22e Part 1 p. 1150-1152