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

Answer and Explanation

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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Correct Answer is A

Explanation

A. Flaring of the nares:
Flaring of the nares is a clinical sign of respiratory distress in newborns. It indicates that the infant is working harder to breathe and is attempting to increase the size of the nostrils to get more air.

B. Shallow and irregular respirations:
Shallow and irregular respirations can be a sign of respiratory distress, but flaring of the nares is a more specific and immediate indication.

C. Respiratory rate of 50 breaths per minute:
While a respiratory rate of 50 breaths per minute might be within the normal range for a newborn, the overall clinical picture, including other signs of distress, should be considered.

D. Abdominal breathing with synchronous chest movement:
Abdominal breathing with synchronous chest movement is not a normal pattern for a newborn and could indicate respiratory distress.

A. Cleanse the spinal injection site B. Apply an abdominal binder C. Insert an indwelling Foley catheter D. Place procedure equipment at bedside

Correct Answer is D

Explanation

A. Cleanse the spinal injection site:
Cleansing the spinal injection site is a routine part of maintaining proper hygiene during and after the administration of spinal anesthesia. However, if the client is experiencing symptoms of a spinal headache, the priority is to prepare for potential interventions by having the necessary equipment ready rather than focusing on the site itself.

B. Apply an abdominal binder:
Applying an abdominal binder is not directly related to addressing a spinal headache. Abdominal binders are typically used for providing support to the abdominal muscles after childbirth or surgery. It wouldn't be the primary intervention for a spinal headache.

C. Insert an indwelling Foley catheter:
Inserting an indwelling Foley catheter is not a direct intervention for addressing a spinal headache. Spinal headaches are related to cerebrospinal fluid leakage and positioning. While managing the patient's overall care is important, it may not be the immediate priority in this context.

D. Place procedure equipment at bedside:
This is the most appropriate action in the context of a postpartal client exhibiting symptoms of a spinal headache. Having the necessary procedure equipment, such as materials for a blood patch, ready at the bedside ensures preparedness for potential interventions by the anesthesiologist.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is performing a newborn assessment. Which symptom, if present in a newborn, would indicate respiratory distress?

Correct Answer is A

Explanation

The nurse is caring for a postpartal client who is exhibiting symptoms of a spinal headache 24 hours following delivery of a normal newborn. Prior to the anesthesiologist's arrival on the unit, which action should the nurse perform?

Correct Answer is D

Explanation

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