A full-term infant is admitted to the newborn nursery 2 hours after delivery.The delivery record indicates the mother is positive for human immunodeficiency virus (HIV) and received zidovudine intravenously during labor.
Which action should the nurse implement?

Obtain consent for the Hepatitis B vaccine.

Collect a venous specimen for serum glucose level.

Assess for the presence of the Moro reflex.

Ensure that zidovudine is given within 6 hours after birth.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Obtaining consent for the Hepatitis B vaccine is a necessary step in the newborn's care, but it is not the immediate priority for a newborn exposed to HIV. The focus should be on preventing HIV transmission from mother to child.

Choice B rationale

Collecting a venous specimen for serum glucose level is important for assessing the newborn's metabolic status, but it does not directly address the immediate need to reduce the risk of HIV transmission.

Choice C rationale

Assessing for the presence of the Moro reflex is part of a routine newborn examination and is important for evaluating the neurological status of the newborn. However, it does not address the immediate priority of HIV prophylaxis.

Choice D rationale

Ensuring that zidovudine is given within 6 hours after birth is critical for reducing the risk of mother-to-child transmission of HIV. Early administration of antiretroviral medication is essential to prevent viral replication and transmission to the newborn.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A rationale

Documenting the vital signs in the medical record is appropriate as the vital signs provided fall within expected ranges for a postpartum client. A temperature of 100.4°F (38°C) can be normal due to dehydration or exertion from labor, and bradycardia (heart rate 58 beats/minute) is common in postpartum women due to increased stroke volume and cardiac output.

Choice B rationale

Assessing the perineum for excessive lochia is important if there are concerns about postpartum hemorrhage, but it is not directly related to the provided vital signs. While lochia should be monitored, the vital signs alone do not indicate excessive bleeding or other complications.

Choice C rationale

Administering acetaminophen for a temperature of 100.4°F (38°C) may not be necessary, as this temperature can be considered within normal limits postpartum. Fever above 100.4°F may warrant medication, but the provided vital signs suggest no immediate need for intervention.

Choice D rationale

Reporting the heart rate to the healthcare provider is unnecessary because bradycardia (heart rate 58 beats/minute) is normal in postpartum women. Increased stroke volume during the postpartum period can result in lower heart rates. The vital signs provided do not indicate a cause for concern.

A. Latanoprost eye drops. B. Erythromycin ointment. C. Tetracaine eye drops. D. Neomycin ointment.

Correct Answer is B

Explanation

Choice A rationale

Latanoprost eye drops are used to reduce intraocular pressure in glaucoma patients and are not relevant for a newborn exposed to Neisseria gonorrhoeae.

Choice B rationale

Erythromycin ointment is the correct medication to administer to a newborn exposed to Neisseria gonorrhoeae. It is used to prevent ophthalmia neonatorum, an eye infection caused by the bacteria. Administering erythromycin ointment is essential to protect the newborn's eyes from potential blindness or severe infection.

Choice C rationale

Tetracaine eye drops are a topical anesthetic used to numb the eyes during procedures and are not indicated for preventing neonatal eye infections caused by Neisseria gonorrhoeae.

Choice D rationale

Neomycin ointment is an antibiotic used for treating bacterial infections, but it is not the standard treatment for preventing ophthalmia neonatorum in newborns exposed to Neisseria gonorrhoeae. Erythromycin ointment is the recommended prophylactic treatment. .

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A full-term infant is admitted to the newborn nursery 2 hours after delivery.The delivery record indicates the mother is positive for human immunodeficiency virus (HIV) and received zidovudine intravenously during labor. Which action should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The current vital signs for a primipara who delivered vaginally during the previous shift are: temperature 100.4°F (38°C), heart rate 58 beats/minute, respiratory rate 16 breaths/minute, and blood pressure 130/74 mm Hg. Which action should the nurse implement?

Correct Answer is A

Explanation

A client who is positive for Neisseria gonorrhoeae vaginally delivered a newborn.Which medication should the nurse administer to the newborn?

Correct Answer is B

Explanation

The nurse is caring for a newborn with suspected neonatal abstinence syndrome.The mother is currently taking methadone and is in a treatment program.Which intervention should the nurse implement prior to discharge?

After two miscarriages, a client is instructed to increase her daily intake of foods that includes folic acid.The client does not like green leafy vegetables and states she is allergic to soy. Which food should the nurse suggest that the client eat to obtain folic acid?

A full-term infant is admitted to the newborn nursery 2 hours after delivery.The delivery record indicates the mother is positive for human immunodeficiency virus (HIV) and received zidovudine intravenously during labor. Which action should the nurse implement?

A client whose labor is being augmented with an oxytocin infusion requests an epidural for pain control.Findings of the last vaginal exam, performed one hour ago, were 3 cm cervical dilation, 60% effacement, and a -2 station.Which action should the nurse implement first?

In preparing a gravid client for a triple screen analysis, which action should the nurse take?

A full-term infant is admitted to the newborn nursery 2 hours after delivery.The delivery record indicates the mother is positive for human immunodeficiency virus (HIV) and received zidovudine intravenously during labor.
Which action should the nurse implement?