Chapter 7

Question 1

1. Syphilis is a complex disease that can lead to serious systemic illness and even death if left untreated. Which manifestation differentiates primary syphilis from secondary syphilis?
   a. Fever, headache, and malaise
   b. Widespread rash
   c. Identified by serologic testing
   d. Appearance of a chancre 2 months after infection

Answer 1

ANS: D
Primary syphilis is characterized by a primary lesion (the chancre), which appears 5 to 90 days after infection. The chancre begins as a painless papule at the site of inoculation and erodes to form a nontender, shallow, and clean ulcer several millimeters to centimeters in size. Secondary syphilis occurs 6 weeks to 6 months after the appearance of the chancre and is characterized by a widespread maculopapular rash. The individual may also experience fever, headache, and malaise. Latent syphilis are those infections that lack clinical manifestations; however, they are detected by serologic testing.

Question 2

2. The human papillomavirus (HPV), also known as genital warts, affects 79 million Americans, with an estimated number of 14 million new infections each year. The highest rate of infection occurs in young women, ages 20 to 24 years. Prophylactic vaccination to prevent the HPV is now available. Which statement regarding this vaccine is inaccurate?
   a. Only one vaccine for the HPV is available.
   b. The vaccine is given in three doses over a 6-month period.
   c. The vaccine is recommended for both boys and girls.
   d. Ideally, the vaccine is administered before the first sexual contact.

Answer 2

ANS: A
Two vaccines for HPV are available—Cervarix and Gardasil—and other vaccines continue to be investigated. These vaccines protect against HPV types 6, 11, 16, and 18. They are most effective if administered before the first sexual contact. Recommendations are that vaccines be administered to 11- and 12-year-old girls and boys. The vaccine can be given to girls as young as 9 years of age and young women ages 13 to 26 years in three doses over a 6-month period.

Question 3

3. Which sexually transmitted infection (STI) is the most commonly reported in American women?
   a. Gonorrhea
   b. Syphilis
   c. Chlamydia
   d. Candidiasis

Answer 3

ANS: C
Chlamydia is the most common and fastest spreading STI among American women, with an estimated 3 million new cases each year. Infection rates are two and a half times that of men. Gonorrhea is probably the oldest communicable disease in the United States and second to Chlamydia in reported conditions. Syphilis is the earliest described STI. Candidiasis is a relatively common fungal infection.

Question 4

4. The Centers for Disease Control and Prevention (CDC) recommends which therapy for the treatment of the HPV?
   a. Miconazole ointment
   b. Topical podofilox 0.5% solution or gel
   c. Two doses of penicillin administered intramuscularly (IM)
   d. Metronidazole by mouth

Answer 4

ANS: B
Available treatments are imiquimod, podophyllin, and podofilox. Miconazole ointment is used to treat athlete’s foot. Penicillin IM is used to treat syphilis. Metronidazole is used to treat bacterial vaginosis.

Question 5

5. A client exhibits a thick, white, lumpy, cottage cheese–like discharge, along with white patches on her labia and in her vagina. She complains of intense pruritus. Which medication should the nurse practitioner order to treat this condition?
   a. Fluconazole
   b. Tetracycline
   c. Clindamycin
   d. Acyclovir

Answer 5

ANS: A
The client is experiencing a candidiasis infection. Fluconazole, metronidazole, and clotrimazole are the drugs of choice to treat this condition. Tetracycline is used to treat syphilis. Clindamycin is used to treat bacterial vaginosis. Acyclovir is used to treat genital herpes.

Question 6

6. Which laboratory testing is used to detect the human immunodeficiency virus (HIV)?
   a. HIV screening
   b. HIV antibody testing
   c. Cluster of differentiation 4 (CD4) counts
   d. Cluster of differentiation 8 (CD8) counts

Answer 6

ANS: B
The screening tool used to detect HIV is the enzyme immunoassay, which tests for the presence of antibodies to the HIV. HIV-1 and HIV-2 antibody tests are used to confirm the diagnosis. To determine whether the HIV is present, the test performed must be able to detect antibodies to the virus, not the virus itself. CD4 counts are associated with the incidence of acquired immunodeficiency syndrome (AIDS) in HIV-infected individuals. CD8 counts are not performed to detect HIV.

Question 7

7. Which condition is the most life-threatening virus to the fetus and neonate?
   a. Hepatitis A virus (HAV)
   b. Herpes simplex virus (HSV)
   c. Hepatitis B virus (HBV)
   d. Cytomegalovirus (CMV)

Answer 7

ANS: C
HBV is the most life-threatening viral condition to the fetus and neonate. HAV is not the most threatening to the fetus nor is HSV the most threatening to the neonate. Although serious, CMV is not the most life-threatening viral condition to the fetus.

Question 8

8. Which treatment regime would be most appropriate for a client who has been recently diagnosed with acute pelvic inflammatory disease (PID)?
   a. Oral antiviral therapy
   b. Bed rest in a semi-Fowler position
   c. Antibiotic regimen continued until symptoms subside
   d. Frequent pelvic examination to monitor the healing progress

Answer 8

ANS: B
The woman with acute PID should be on bed rest in a semi-Fowler position. Broad-spectrum antibiotics are used; antiviral therapy is ineffective. Antibiotics must be taken as prescribed, even if symptoms subside. Few pelvic examinations should be conducted during the acute phase of the disease.

Question 9

9. On vaginal examination of a 30-year-old woman, the nurse documents the following findings: profuse, thin, grayish-white vaginal discharge with a “fishy” odor and complaints of pruritus. Based upon these findings, which condition would the nurse suspect?
   a. Bacterial vaginosis
   b. Candidiasis
   c. Trichomoniasis
   d. Gonorrhea

Answer 9

ANS: A
Most women with bacterial vaginosis complain of a characteristic “fishy” odor. The discharge is usually profuse, thin, and has a white, gray, or milky color. Some women may also experience mild irritation or pruritus. The discharge associated with candidiasis is thick, white, and lumpy and resembles cottage cheese. Trichomoniasis may be asymptomatic, but women commonly have a characteristic yellow-to-green, frothy, mucopurulent, copious, and malodorous discharge. Women with gonorrhea are often asymptomatic. Although they may have a purulent endocervical discharge, the discharge is usually minimal or absent.

Question 10

10. Which viral sexually transmitted infection is characterized by a primary infection followed by recurrent episodes?
    a. Herpes simplex virus 2 (HSV-2)
    b. HPV
    c. HIV
    d. CMV

Answer 10

ANS: A
The initial HSV genital infection is characterized by multiple painful lesions, fever, chills, malaise, and severe dysuria; it may last 2 to 3 weeks. Recurrent episodes of the HSV infection commonly have only local symptoms that usually are less severe than those of the initial infection. With HPV infection, lesions are a chronic problem. The HIV is a retrovirus. Seroconversion to HIV positivity usually occurs within 6 to 12 weeks after the virus has entered the body. Severe depression of the cellular immune system associated with the HIV infection characterizes AIDS, which has no cure. In most adults, the onset of CMV infection is uncertain and asymptomatic. However, the disease may become a chronic, persistent infection.

Question 11

11. The nurse should understand the process by which the HIV infection occurs. Once the virus has entered the body, what is the time frame for seroconversion to HIV positivity?
    a. 6 to 10 days
    b. 2 to 4 weeks
    c. 6 to 12 weeks
    d. 6 months

Answer 11

ANS: C
Seroconversion to HIV positivity usually occurs within 6 to 12 weeks after the virus has entered the body. Both 6 to 10 days and 2 to 4 weeks are too short for seroconversion to HIV positivity to occur, and 6 months is too long.

Question 12

12. A 25-year-old single woman comes to the gynecologist’s office for a follow-up visit related to her abnormal Papanicolaou (Pap) smear. The test revealed that the client has the HPV. The woman asks, “What is that? Can you get rid of it?” Which is the best response for the nurse to provide?
    a. “It’s just a little lump on your cervix. We can just freeze it off.”
    b. “HPV stands for ‘human papillomavirus.’ It is a sexually transmitted infection that may lead to cervical cancer.”
    c. “HPV is a type of early human immunodeficiency virus. You will die from this.”
    d. “You probably caught this from your current boyfriend. He should get tested for this.”

Answer 12

ANS: B
Informing the client about STIs and the risks involved with the HPV is important. The health care team has a duty to provide proper information to the client, including information related to STIs and the fact that although the HPV and HIV are both viruses that can be sexually transmitted, they are not the same virus. The onset of the HPV can be insidious. Often STIs go unnoticed. Abnormal bleeding is frequently the initial symptom. The client may have had the HPV before her current boyfriend. The nurse should make no deductions from this limited information.

Question 13

13. Which STI does not respond well to antibiotic therapy?
    a. Chlamydia
    b. Gonorrhea
    c. Genital herpes
    d. Syphilis

Answer 13

ANS: C
Genital herpes is a chronic and recurring disease for which no known cure is available; therefore, it does not respond to antibiotics. Chlamydia is a bacterial infection that is treated with doxycycline or azithromycin. Gonorrhea is a bacterial infection that is treated with any of several antibiotics. Syphilis is a bacterial infection that is treated with penicillin.

Question 14

14. Five different viruses (A, B, C, D, and E) account for almost all cases of hepatitis infections. Which statement regarding the various forms of hepatitis is most accurate?
    a. Vaccine exists for hepatitis C virus (HCV) but not for HBV.
    b. HAV is acquired by eating contaminated food or drinking polluted water.
    c. HBV is less contagious than HIV.
    d. Incidence of HCV is decreasing.

Answer 14

ANS: B
Contaminated milk and shellfish are common sources of infection for HAV. A vaccine exists for HBV but not for HCV. HBV is more contagious than HIV. The incidence of HCV is on the rise.

Question 15

15. A 21-year-old client exhibits a greenish, copious, and malodorous discharge with vulvar irritation. A speculum examination and wet smear are performed. Which condition is this client most likely experiencing?
    a. Bacterial vaginosis
    b. Candidiasis
    c. Yeast infection
    d. Trichomoniasis

Answer 15

ANS: D
Although uncomfortable, a speculum examination is always performed and a wet smear obtained if the client exhibits symptoms of trichomoniasis. The presence of many white blood cell protozoa is a positive finding for trichomoniasis. A normal saline test is used to test for bacterial vaginosis. A potassium hydroxide preparation is used to test for candidiasis. Yeast infection is the common name for candidiasis, for which the test is a potassium hydroxide preparation.

Question 16

16. An essential component of counseling women regarding safe sex practices includes a discussion regarding avoiding the exchange of body fluids. The most effective physical barrier promoted for the prevention of STIs and HIV is the condom. To educate the client about the use of condoms, which information related to condom use is the most important?
    a. Strategies to enhance condom use
    b. Choice of colors and special features
    c. Leaving the decision up to the male partner
    d. Places to carry condoms safely

Answer 16

ANS: A
When the nurse opens the discussion on safe-sex practices, it gives the woman permission to clear up any concerns or misapprehensions that she may have regarding condom use. The nurse can also suggest ways that the woman can enhance her condom negotiation and communications skills with a sexual partner. These include role-playing, rehearsal, cultural barriers, and situations that place the client at risk. Although women can be taught the differences among condoms, such as size ranges, where to purchase, and price, these features are not as important as negotiating the use of safe sex practices. Although not ideal, women may safely choose to carry condoms in shoes, wallets, or inside their bra. They should be taught to keep the condom away from heat. Although this information is important, it is not relevant if the woman cannot even discuss strategies on how to enhance condom use.

Question 17

17. Group B Streptococcus (GBS) is part of the normal vaginal flora in 20% to 30% of healthy pregnant women. GBS has been associated with poor pregnancy outcomes and is an important factor in neonatal morbidity and mortality. Which finding is not a risk factor for neonatal GBS infection?
    a. Positive prenatal culture
    b. Preterm birth at 37 weeks or less of gestation
    c. Maternal temperature of 38 C or higher
    d. Premature rupture of membranes (PROM) 24 hours or longer before the birth

Answer 17

ANS: D
PROM 18 hours or longer before the birth increases the risk for neonatal GBS infection. Positive prenatal culture is a risk factor for neonatal GBS infection. Preterm birth at 37 weeks or less of gestation remains a risk factor for neonatal GBS infection. Maternal temperature of 38 C or higher is also a risk factor for neonatal GBS infection.

Question 18

18. Clients treated for syphilis with penicillin may experience a Jarisch-Herxheimer reaction. Which clinical presentation would be unlikely if a client is experiencing this reaction?
    a. Vomiting and diarrhea
    b. Headache, myalgias, and arthralgia
    c. Preterm labor
    d. Jarisch-Herxheimer in the first 24 hours after treatment

Answer 18

ANS: A
The Jarisch-Herxheimer reaction is an acute febrile reaction that occurs within the first 24 hours of treatment and is accompanied by headache, myalgias, and arthralgia. Vomiting and diarrhea are not anticipated. If the client is pregnant, then she is at risk for preterm labor and birth.

Question 19

19. The health history and physical examination cannot reliably identify all persons infected with HIV or other blood-borne pathogens. Which infection control practice should the nurse use when providing eye prophylaxis to a term newborn?
    a. Wear gloves.
    b. Wear mouth, nose, and eye protection.
    c. Wear a mask.
    d. Wash the hands after medication administration.

Answer 19

ANS: A
Standard Precautions should be consistently used in the care of all persons. Personal protective equipment in the form of gloves should be worn during infant eye prophylaxis, care of the umbilical cord, circumcision site care, diaper changes, handling of colostrum, and parenteral procedures. Masks are worn during respiratory isolation or if the health care practitioner has a cough. Mouth, eye, and nose protection are used to protect the mucous membranes if client-care activities are likely to generate splashes or sprays of body fluids. The hands should be washed both before having contact with the client and after administering medications.

Question 20

20. The nurse providing care in a women’s health care setting must be knowledgeable about STIs. Which STIs can be successfully treated?
    a. HSV
    b. AIDS
    c. Venereal warts
    d. Chlamydia

Answer 20

ANS: D
The usual treatment for Chlamydia bacterial infection is doxycycline or azithromycin. Concurrent treatment of all sexual partners is needed to prevent recurrence. No known cure is available for HSV; therefore, the treatment focuses on pain relief and preventing secondary infections. Because no cure is known for AIDS, prevention and early detection are the primary focus of care management. HPV causes condylomata acuminata (venereal warts); no available treatment eradicates the virus.

Question 21

21. What is the drug of choice for the treatment of gonorrhea?
    a. Penicillin G
    b. Tetracycline
    c. Ceftriaxone
    d. Acyclovir

Answer 21

ANS: C
Ceftriaxone is effective for the treatment of all gonococcal infections. Penicillin is used to treat syphilis. Tetracycline is prescribed for chlamydial infections. Acyclovir is used to treat herpes genitalis.

Question 22

1. Which sexual behaviors are associated with exposure to an STI? (Select all that apply.)
   a. Fellatio
   b. Unprotected anal intercourse
   c. Multiple sex partners
   d. Dry kissing
   e. Abstinence

Answer 22

ANS: A, B, C
Engaging in fellatio, unprotected anal intercourse, or having multiple sex partners increases the exposure risk and the possibility of acquiring an STI. Dry kissing and abstinence are considered safe sexual practices.

Question 23

2. Which statements regarding the HPV are accurate? (Select all that apply.)
   HPV infections:
   a. are thought to be less common in pregnant women than in women who are not pregnant.
   b. are thought to be more common in pregnant women than in women who are not pregnant.
   c. were previously called genital warts.
   d. were previously called herpes.
   e. may cause cancer.

Answer 23

ANS: B, C, E
HPV infections are thought to be more common in pregnant women than in women who are not pregnant, with an increase in incidence from the first trimester to the third trimester. HPV, formerly called venereal or genital warts, is an STI with more than 30 known serotypes, several of which are associated with cervical cancer.

Question 24

3. A 23-year-old primiparous client with inconsistent prenatal care is admitted to the hospital’s maternity unit in labor. The client states that she has tested positive for the HIV. She has not undergone any treatment during her pregnancy. The nurse understands that the risk of perinatal transmission can be significantly decreased by a number of prophylactic interventions. Which interventions should be included in the plan of care?
   a. Intrapartum treatment with antiviral medications
   b. Cesarean birth
   c. Postpartum treatment with antiviral medications
   d. Avoidance of breastfeeding
   e. Pneumococcal, HBV, and Haemophilus influenzae vaccine

Answer 24

ANS: A, B, D
The prophylactic measures of prenatal antiviral use, elective cesarean birth, and formula feeding reduce the transmission of the HIV to as low as 1% to 2%. The client who refuses a cesarean birth should be given intravenous antiviral therapy during labor. Ideally, medications should be given prenatally. Administration of antiviral drugs in the postpartum period will not reduce transmission to the infant. All women who are HIV positive should be encouraged to receive these immunizations. They will not reduce the risk of perinatal transmission.

Question 25

4. A group of infections known collaboratively as TORCH infections are capable of crossing the placenta and causing serious prenatal effects on the fetus. Which infections are included in this group of organisms? (Select all that apply.)
   a. Toxoplasmosis
   b. Other infections
   c. Roseola
   d. Clostridium
   e. Herpes simplex

Answer 25

ANS: A, B, E
Toxoplasmosis, other infections, rubella virus, CMV, and HSV are collectively known as TORCH infections. Generally, all TORCH infections produce influenza-like symptoms in the mother; however, fetal effects are generally more serious.

Question 26

5. The nurse should be familiar with the use of the five Ps as a tool for evaluating risk behaviors for STIs and the HIV. Which components would the nurse include in her use of the five Ps as an assessment tool? (Select all that apply.)
   a. Number of partners
   b. Level of physical activity
   c. Prevention of pregnancy
   d. Protection from STIs
   e. Past history

Answer 26

ANS: A, C, D, E
Level of physical activity is not a component of this assessment. The five Ps include partners, prevention of pregnancy, protection from STIs, understanding of sexual practices, and past history.

Question 27

6. Counseling and education are critical components of the nursing care of women with herpes infections. Clients should be taught to identify triggers that might result in a herpes attack. Which factors are possible triggers for a recurrence? (Select all that apply.)
   a. Menstruation
   b. Trauma
   c. Febrile illness
   d. Soap
   e. Ultraviolet light

Answer 27

ANS: A, B, C, E
Stress, menstruation, trauma, febrile illness, chronic illnesses, and ultraviolet light have all been found to trigger genital herpes. Women might elect to keep a diary of symptoms to help identify stressors. Lesions should be cleansed with saline or simple soap and water. Lesions can be kept dry by using a blow dryer, wearing cotton underwear, and wearing loose clothing. Tea bags or hydrogen peroxide might also be helpful.

Question 28

The Centers for Disease Control and Prevention (CDC)–recommended medication for the treatment of chlamydia is:
  A. Doxycycline Correct
  B. Podofilox
  C. Acyclovir
  D. Penicillin

Answer 28

Ans: A
Doxycycline is effective for treating chlamydia; however, it should be avoided if a woman is pregnant. Podofilox is a recommended treatment for nonpregnant women diagnosed with human papillomavirus infection. Acyclovir is recommended for genital herpes simplex virus infection. Penicillin is the preferred medication for syphilis.

Question 29

The viral sexually transmitted infection (STI) that affects most people in the United States today is:
  A. Herpes simplex virus type 2 (HSV-2)
  B. Human papillomavirus (HPV) 
  C. Human immunodeficiency virus (HIV)
  D. Cytomegalovirus (CMV)

Answer 29

Ans: B

HPV infection is the most prevalent viral STI seen in ambulatory health care settings.

Question 30

The recommended treatment to prevent transmission of human immunodeficiency virus (HIV) to the fetus during pregnancy is:
  A. Acyclovir
  B. Ofloxacin
  C. Podophyllin
  D. Zidovudine

Answer 30

Ans: D
Perinatal transmission of HIV has decreased significantly in the past decade as a result of prophylactic administration of the antiretroviral drug zidovudine to pregnant women in the prenatal and perinatal periods. Acyclovir is an antiviral treatment for herpes simplex virus (HSV). Ofloxacin is an antibacterial treatment for gonorrhea. Podophyllin is a solution used in the treatment of human papillomavirus.

Question 31

When teaching self-care prevention of genital tract infections, the nurse should instruct the woman to:
A. Increase dietary sugar and avoid yogurt.
B. Limit time spent in damp exercise clothes and limit exposure to bath salts or bubble bath.
C. Choose underwear or hosiery with a nylon crotch.
D. Douche frequently.

Answer 31

Ans: B
Clinical observations and research have suggested that tight-fitting clothing and underwear or pantyhose made of nonabsorbent materials (like nylon) create an environment in which a vaginal fungus can grow. Bathing in bath salts or bubble bath may further irritate sensitive genital tissue. Douching can irritate tissue, alter pH, and create an environment conducive to fungal growth. Prevention of genital tract infections includes reducing dietary sugar and eating yogurt.

Question 32

With regard to the most common bacterial sexually transmitted infections, which statement is not accurate?
A. Chlamydial infections and gonorrhea are more likely to occur in women younger than age 20.
B. Gonorrhea can be transmitted to the newborn by direct contact with gonococcal organisms in the cervix.
C. Syphilis can be transmitted through kissing, biting, or oral-genital sex.
D. Medications for pelvic inflammatory disease can be discontinued once symptoms disappear.

Answer 32

Ans: D

For any infection, the entire prescription must always be taken.

Question 33

An essential component of counseling women regarding safe sex practices is discussion about avoiding the exchange of body fluids. The physical barrier promoted for the prevention of sexually transmitted infections (STIs) and human immunodeficiency virus (HIV) is the condom. Nurses can help motivate clients to use condoms by initiating a discussion related to a number of aspects of condom use. The most important of these is:
A. Strategies to enhance condom use.
B. Choice of colors and special features.
C. Leaving the decision up to the male partner.
D. Places to safely carry condoms.

Answer 33

Ans: A
When the nurse opens discussion on safe sex practices, the woman is given permission to clear up any concerns or misapprehensions she may have regarding condom use. The nurse can also suggest ways that the woman can enhance her condom negotiation and communications skills, such as role-playing, rehearsal, cultural barriers, and situations that put the client at risk. Although women can be taught the differences among condoms (such as size ranges, where to purchase, and price), this issue is not as important as negotiating the use of safe sex practices. Women must address the issue of condom use with every sexual contact. Some men need time to think about using condoms; if a man appears reluctant, the woman may want to reconsider the relationship. Although not ideal, women may safely carry condoms in shoes, wallets, or inside their bras. They should be taught to keep condoms away from heat. This information is important but is not germane if the woman cannot even discuss strategies on how to enhance condom use.

Question 34

Which statement about genital herpes is inaccurate?
A. Genital herpes is also known as genital warts.
B. Stress, menstruation, trauma, and illnesses have been known to trigger recurrences.
C. Genital herpes is chronic and recurring and has no known cure.
D. Plain soap and water are all that is needed to clean hands that have come into contact with herpetic lesions.

Answer 34

Ans: A
Genital warts are one of the most common sexually transmitted infections (STIs); however, it is also known as human papillomavirus (HPV), not genital herpes.

Question 35

Group B streptococcus (GBS) is part of the normal vaginal flora in 20% to 30% of healthy pregnant women. GBS has been associated with poor pregnancy outcomes and is an important factor in neonatal morbidity and mortality. Which of the following would not be considered to be a risk factor for neonatal GBS infection?
A. Positive prenatal culture result
B. Preterm birth at less than 37 weeks of gestation
C. Maternal fever of 38° C or greater
D. Premature rupture of membranes for longer than 24 hours

Answer 35

Ans: D

Premature rupture of membranes for 18 hours or more increases the risk for neonatal GBS infection.

Question 36

A patient who is breastfeeding has been diagnosed with Gonorrhea. Which treatment plan should be instituted?
A. Amoxicillin 500 mg three times a day for 1 week
B. Benzathine penicillin G 2.4 million units one injection
C. Amoxicillin 500 mg three times a day for 7 days and ceftriaxone 250 mg IM injection Correct
D. Ceftriaxone 250 mg IM injection

Answer 36

Amoxicillin or ceftriaxone can be part of the treatment plan for gonorrhea but the patient should be treated empirically for chlamydia as well. Dual therapy with amoxicillin and ceftriaxone can be used for treatment of gonorrhea and empirical treatment of chlamydia. Benzathine penicillin is indicated for treatment of syphilis for the lactating patient.

Question 37

In providing health promotion education to reduce the likelihood of transmission of sexually transmitted diseases, the nurse would describe which of the following practices as having a low but potential risk for disease transmission? (Select all that apply.)
A. Erotic conversation
B. Oral-anal contact
C.Oral sex with female or male wearing condom Correct
D. Vaginal intercourse with condom Correct
E. Blood contact during sexual act due to menses

Answer 37

Ans: C, D
Erotic conversation would be considered a safe risk reduction practice. Oral-anal contact and blood contact during a sexual act due to menses would be considered high-risk practices. Both oral sex and vaginal sex while wearing condoms are practices with low but potential risks.