A nurse is planning care for a client who is pregnant and has HIV.
Which of the following actions should the nurse include in the plan of care?
Use a fetal scalp electrode during labor and delivery.
Bathe the newborn before initiating skin-to-skin contact.
Instruct the client to stop taking the antiretroviral medications at 32 weeks of gestation.
Administer a pneumococcal immunization to the newborn within 4 hours
The Correct Answer is B
Bathing the newborn before initiating skin-to-skin contact is an action that the nurse should include in the plan of care for a client who is pregnant and has HIV.
Choice A is incorrect because using a fetal scalp electrode during labor and delivery is not mentioned as an action that should be included in the plan of care for a client who is pregnant and has HIV in my sources.
Choice C is incorrect because instructing the client to stop taking antiretroviral medications at 32 weeks of gestation is not mentioned as an action that should be included in the plan of care for a client who is pregnant and has HIV in my sources.
Choice D is incorrect because administering a pneumococcal immunization to the newborn within 4 hours following birth is not mentioned as an action that should be included in the plan of care for a client who is pregnant and has HIV in my sources.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A, B, C, D
Explanation
The correct answer is A, B, C, D.
The nurse should plan to perform the following actions in this order:
A. Ask the client to lie on her back and with her knees flexed.
B. Position one hand around the top of the client’s fundus and one hand just above the client’s symphysis pubis.
C. Rotate the upper hand to massage the client’s uterus while using slight downward pressure to compress the fundus.
D. Observe the client’s perineum for the passage of clots and the amount of
bleeding.
Fundal massage is performed to stimulate uterine contractions and prevent
postpartum hemorrhage.
Correct Answer is C
Explanation
Retained placental fragments is a risk factor for postpartum hemorrhage. After delivery, the uterus continues to contract to deliver the placenta.
Contractions also help to compress the blood vessels where the placenta was atached to the uterine wall.
Postpartum hemorrhage can happen if parts of the placenta stay atached to the
uterine wall.
Choice A is incorrect because pregnancy-induced hypertension is a risk factor for
postpartum hemorrhage.
Choice B is incorrect because meconium-stained fluid is not mentioned as a risk factor for postpartum hemorrhage in my sources.
Choice D is incorrect because oligohydramnios is not mentioned as a risk factor for postpartum hemorrhage in my sources.
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