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?
Instruct the client to stop taking the antiretroviral medications at 32 weeks of gestation.
Use a foetal scalp electrode during labor and delivery
Bathe the newborn before initiating skin-to-skin contact.
Administer a pneumococcal immunization to the newborn within 4 hr following birth.
The Correct Answer is C
Pregnant clients with HIV require comprehensive care during pregnancy, delivery, and postpartum periods to prevent transmission of HIV to the newborn. Bathing the newborn before initiating skin-to-skin contact is a recommended action to reduce the risk of HIV transmission from mother to child. This practice helps to remove any maternal blood or other bodily fluids from the newborn's skin, which may contain the virus. Therefore, the nurse should instruct the client to bathe the newborn before initiating skin-to-skin contact.
Antiretroviral medications are usually continued throughout pregnancy and during labor and delivery to decrease the risk of transmission to the newborn. Therefore, the nurse should not instruct the client to stop taking antiretroviral medications at 32 weeks of gestation, as mentioned in option a.
Fetal scalp electrode is a device that ataches to the baby's scalp to monitor the fetal heart rate. This device can cause small cuts or abrasions on the baby's scalp, which may increase the risk of HIV transmission.
Therefore, its use should be avoided in clients with HIV. Therefore, option b is not a recommended action.
Administering pneumococcal immunization to the newborn within 4 hours following birth is not a recommended action in the plan of care for a client who is pregnant and has HIV. Pneumococcal immunization is not indicated for newborns immediately after birth. Therefore, option d is not a recommended action.
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Related Questions
Correct Answer is C
Explanation
Absent deep tendon reflexes are a sign of magnesium toxicity, which can occur with high levels of magnesium in the bloodstream. This can be a serious complication that requires immediate atention from the provider.
Option A, a decrease in frequency of contractions, is actually a desired effect of magnesium sulfate in the management of preterm labor. It is not a cause for concern.
Option B, a blood pressure reading of 150/100 mm Hg, is high, but it is not necessarily related to the administration of magnesium sulfate. However, it should still be reported to the provider for appropriate management.
Option D, a urinary output of 35 mL/hr, is below the normal range but it may still be within an acceptable range for a client receiving magnesium sulfate. The provider should be notified if urinary output continues to decrease or if it falls below a certain threshold.
Correct Answer is D
Explanation
A) Hypertension is not typically an adverse reaction to magnesium sulfate; this medication is actually used to lower high blood pressure in preeclampsia.
B) Hypoglycemia is also not a common adverse reaction to magnesium sulfate. This medication does not typically affect blood sugar levels.
C) A respiratory rate of 16/min is within normal limits and is not indicative of an adverse reaction to magnesium sulfate, which can cause respiratory depression if it does affect breathing.
D) Urine output of 20 mL/hr is a concerning sign and can indicate nephrotoxicity or acute kidney injury, which are possible adverse reactions to magnesium sulfate, especially in the context of preeclampsia where kidney function must be closely monitored.
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