A client at 40-weeks gestation is admitted in active labor, and laboratory findings indicate that she is HIV positive. Which actions should the nurse plan to perform? (Select all that apply.)
Place client in a negative pressure room
Implement droplet precautions
Encourage the mother to bottle-feed
Give antiviral medication intravenously
Use standard precautions
Correct Answer : E
A. Place client in a negative pressure room: Negative pressure rooms are typically used for airborne precautions, not for preventing the transmission of HIV, which primarily requires standard precautions.
B. Implement droplet precautions: HIV does not spread through respiratory droplets. Droplet precautions are for diseases like influenza or meningitis that spread through respiratory droplets, not for HIV.
C. Encourage the mother to bottle-feed: This recommendation can vary based on specific circumstances. In many developed countries, the recommendation is for HIV-positive mothers to avoid breastfeeding to reduce the risk of transmitting HIV to the infant. However, this decision should be discussed with healthcare providers and based on individual circumstances.
D. Give antiviral medication intravenously: Antiretroviral medications are used to manage HIV. However, the method of administration and specific medications depend on the client's condition and the stage of pregnancy. Intravenous administration might not be the standard for HIV management during labor.
E. Use standard precautions: Standard precautions are the most appropriate approach. These include wearing gloves, practicing good hand hygiene, and using protective barriers as needed to prevent contact with blood and body fluids, which is the primary mode of HIV transmission.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Hemoglobin A1C: Hemoglobin A1C is a test that reflects the average blood sugar levels over the past two to three months. It is not typically used for diagnosing gestational diabetes.
B. Postprandial blood glucose test: This test measures blood sugar levels after meals. While it can provide information about how the body processes glucose after eating, it's not the primary test for diagnosing gestational diabetes.
C. Fasting blood glucose: This test measures blood sugar levels after a period of fasting. It is a standard test used to diagnose gestational diabetes.
D. Oral glucose tolerance test (OGTT): This test involves fasting overnight and then drinking a glucose solution. Blood sugar levels are tested at intervals afterward. The OGTT is a common diagnostic test for gestational diabetes.
Correct Answer is B
Explanation
A. Document the findings in the record: Documenting the findings is important, but it doesn't address the potential issue of hypoglycemia.
B. Obtain a heel stick blood glucose level: This is the most appropriate action given the signs presented. A low blood glucose level can be a critical issue in newborns and requires prompt evaluation and management.
C. Place a pulse oximeter on the heel: While oxygen saturation monitoring is valuable in certain situations, it may not be the priority in this case where hypoglycemia is suspected.
D. Swaddle the infant in a warm blanket: While maintaining warmth is important, especially if the baby is hypothermic, addressing the potential hypoglycemia takes precedence.
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