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","E"]
Explanation
The nurse should plan to immunize the client with the inactivated influenza vaccine (A) and the diphtheria-acellular pertussis vaccine (E).
The Centers for Disease Control and Prevention (CDC) recommends that pregnant women get two vaccines during every pregnancy: the inactivated flu vaccine and the Tdap vaccine.
The other vaccines listed are not recommended during pregnancy:
- The human papillomavirus vaccine is not recommended during pregnancy.
- The varicella vaccine is not recommended during pregnancy.
- The measles, mumps, and rubella vaccine is not recommended during pregnancy.
Correct Answer is B
Explanation
If a prolapsed cord is identified, the nurse should perform a vaginal examination and ensure the presenting part is pushed upwards to relieve pressure on the cord.
Choice A) is not correct because while it is important to cover the cord with a sterile saline saturated towel if it has prolapsed externally 1, it is not the next action after calling for assistance and notifying the provider.
Choice C) is not correct because administering oxygen via non-rebreather mask at 8 L/min is not mentioned as an immediate intervention for a prolapsed cord .
Choice D) is not correct because initiating an infusion of IV fluids for the client is not mentioned as an immediate intervention for a prolapsed cord .
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