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 : C,D,E
A. Place client in a negative pressure room: HIV is not an airborne disease, and clients with HIV do not require isolation in a negative pressure room. Standard precautions are sufficient to prevent transmission.
B. Implement droplet precautions: HIV is not transmitted via droplets. It is transmitted through contact with blood, certain body fluids, or perinatal exposure. Droplet precautions are not indicated.
C. Encourage the mother to bottle-feed: HIV can be transmitted through breast milk. To prevent vertical transmission postpartum, mothers with HIV are advised to avoid breastfeeding and to use formula or bottle-feed instead.
D. Give antiviral medication intravenously: Intrapartum IV zidovudine should be administered in the following situations: (a) HIV RNA >1,000 copies/mL, (b) unknown HIV RNA, (c) known or suspected lack of adherence since the last HIV RNA result, or (d) a positive expedited antigen/antibody HIV test result during labor (AI).
E. Use standard precautions: Standard precautions are the appropriate infection control measures for caring for clients with HIV. This includes wearing gloves, practicing proper hand hygiene, and avoiding contact with the client's blood and other potentially infectious fluids.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Administer oxygen via facemask: Oxygen administration is generally a step in managing fetal distress. However, when dealing with variable decelerations, the initial action involves repositioning the mother to alleviate potential cord compression, as variable decelerations are often due to compression of the umbilical cord.
B. Turn off the oxytocin infusion: If variable decelerations persist despite repositioning, it might be necessary to discontinue the oxytocin (Pitocin) infusion temporarily. Oxytocin can cause or exacerbate uterine hyperstimulation, which can contribute to fetal distress.
C. Assess cervical dilatation: Assessing cervical dilatation might be a part of the overall assessment but might not directly address the immediate issue of variable decelerations. However, it's essential to monitor the progress of labor as part of the broader assessment.
D. Change the client's position: This is the recommended first action for variable decelerations. Repositioning the mother, such as moving her to a lateral or knee-chest position, can relieve potential cord compression and improve fetal oxygenation.
Correct Answer is D
Explanation
A. Unilateral lower leg pain:
Unilateral lower leg pain can be a symptom of deep vein thrombosis (DVT), which is a serious condition. It requires further assessment and intervention.
B. Soft, spongy fundus:
A soft, spongy fundus is not a normal finding 12 hours postpartum. The fundus should be firm and well-contracted. A soft fundus could indicate uterine atony, a potential cause of postpartum hemorrhage.
C. Saturating two perineal pads per hour:
Saturating two perineal pads per hour is not a normal finding and may indicate excessive bleeding, which is concerning for postpartum hemorrhage. This requires immediate attention.
D. Pulse rate of 56 beats/minute:
A pulse rate of 56 beats per minute can be within the normal range, especially if the client is at rest. However, it's essential to consider the overall clinical picture and whether there are any signs of distress or symptoms associated with a low pulse rate.
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