A mother of a 3-hour-old infant requests information concerning breastfeeding.
The mother has tested positive for human immunodeficiency virus (HIV).A nurse’s response should be based on which fact?

The breast milk can be sterilized to kill the HIV virus, then bottle-fed to the infant.

Colostrum should be expressed and analyzed for the presence of the HIV virus prior to breastfeeding.

Breastfeeding may be initiated if the infant is determined to be HIV positive.

Breastfeeding may be a mode of transmission of the HIV virus.

Answer and Explanation

The Correct Answer is D

This is based on the fact that HIV is a virus that attacks the body’s immune system and is spread through certain body fluids, including breast milk. Perinatal transmission can occur during pregnancy, birth, or breastfeeding. Treatment for HIV (antiretroviral therapy, or ART) substantially reduces the risk of perinatal transmission.

Choice A is wrong because sterilizing breast milk does not kill the HIV virus.

Choice B is wrong because colostrum can also contain the HIV virus and testing it is not feasible or reliable.

Choice C is wrong because breastfeeding may still pose a risk of HIV transmission even if the infant is determined to be HIV positive.

The current recommendation in the United States supports shared decision-making between mothers and their healthcare providers regarding infant feeding. Mothers who have questions about breastfeeding or who want to breastfeed should receive patient-centered, evidence-based counseling on infant feeding options, allowing for shared decision-making.

Counseling should begin before conception, or as early as possible in pregnancy and should be

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Correct Answer is C

Explanation

The correct answer is choice C and explain why.Nipple stimulation can cause uterine contractions and increase the risk of preterm labor, especially in a twin gestation.

The client should avoid nipple stimulation until term or as instructed by the provider.

Choice A is wrong because cocoa butter can help moisturize the skin and prevent itching and dryness.

It does not prevent stretch marks, but it is not harmful.

Choice B is wrong because resting several times a day, lying on the left side, can improve blood flow to the uterus and reduce swelling in the lower extremities.

It is a recommended self-care measure for the third trimester of pregnancy.

Choice D is wrong because drinking at least eight glasses of water a day can prevent dehydration, constipation, and urinary tract infections.

It can also help regulate body temperature and amniotic fluid volume.

Normal ranges for twin gestation are similar to singleton gestation, except for fundal height and weight gain.

The fundal height should be measured in centimeters from the pubic symphysis to the top of the uterus.

It should be approximately equal to the number of weeks of gestation plus or minus 4 cm until 32 weeks, then it may plateau or decrease slightly.

The weight gain should be between 35 and 45 pounds for a normal-weight woman, 25 to 42 pounds for an overweight woman, and 15 to 25 pounds for an obese woman.

A. The newborn’s nostrils flare slightly during respiration. B. The newborn’s hands and feet are blue and feel cool. C. The newborn’s eyes move randomly when his head is turned to the side. D. The newborn’s tongue thrusts forward when it is lightly touched.

Correct Answer is A

Explanation

The correct answer is choice A. The newborn’s nostrils flare slightly during respiration.This is a sign of respiratory distress in a newborn.

Flaring nostrils indicate that the newborn is working hard to breathe and may not be getting enough oxygen.

Choice B is wrong because the newborn’s hands and feet are blue and feel cool.This is a normal finding called acrocyanosis, which occurs due to immature peripheral circulation.

It usually resolves within 24 to 48 hours after birth.

Choice C is wrong because the newborn’s eyes move randomly when his head is turned to the side.This is a normal finding called nystagmus, which occurs due to immature eye muscles and coordination.

It usually disappears by 6 months of age.

Choice D is wrong because the newborn’s tongue thrusts forward when it is lightly touched.This is a normal finding called the extrusion reflex, which helps the newborn to suck and swallow.

It usually fades by 4 months of age.

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A mother of a 3-hour-old infant requests information concerning breastfeeding. The mother has tested positive for human immunodeficiency virus (HIV).A nurse’s response should be based on which fact?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who is 22 weeks pregnant with a twin gestation comes to the clinic. The nurse instructs the client in self-care for the third trimester of pregnancy. Which statement made by the client would indicate the need for further teaching?

Correct Answer is C

Explanation

A nurse is assessing a newborn. Which finding may indicate a problem?

Correct Answer is A

Explanation

A patient had an episiotomy during her delivery. Which nursing action should be included in her plan of care for the first 12 hours?

A nurse is caring for a patient who is receiving oxytocin injection intravenously for labor induction.The nurse should monitor this patient for which adverse effect of oxytocin?

A patient who is attending a family planning clinic is instructed in breast self-examination by a nurse. Which statement by the patient would indicate that she understands the instructions?

A nurse is explaining physiological jaundice to a nursing student.Which of the following should the nurse include when discussing risk factors for neonatal physiological jaundice?

During a class for women in the second trimester of pregnancy, the nurse discusses methods to alleviate back pain. Which statement by a class member would indicate the need for additional instruction?

On her second postpartum day, the mother of a newborn says, “The doctor says the baby has physiologic jaundice. Even though it is supposed to be normal, I don’t understand why it occurs.” Which fact regarding physiologic jaundice should form the basis of the nurse’s response?

Just after a client delivers a baby who weighs 7 pounds (3.18 kg), what is the priority nursing action?

A nurse is caring for a primigravida whose cervix is 2 cm dilated, 75% effaced, and the fetal presenting part is at +2 station. The patient says to the nurse, “I want an epidural now.Why won’t someone give me an epidural?” Which response is most appropriate for the nurse to make?

A mother of a 3-hour-old infant requests information concerning breastfeeding.
The mother has tested positive for human immunodeficiency virus (HIV).A nurse’s response should be based on which fact?