A nurse on the labor and delivery unit is planning care for a client who has human immunodeficiency virus (HIV). Which of the following is an appropriate action for the nurse to take following the birth of the newborn?

Initiate contact precautions for the newborn.

Administer IV antibiotics to the newborn.

Cleanse the newborn immediately after delivery.

Encourage the mother to breastfeed her newborn.

Answer and Explanation

The Correct Answer is C

A. While contact precautions may be necessary for certain infections, they are not specifically required for an HIV-positive mother’s newborn if the infant is not infected. The newborn’s HIV status should be confirmed through testing.

B. IV antibiotics are not routinely administered to newborns of HIV-positive mothers unless there is a specific indication for infection prevention or treatment.

C. It is crucial to clean the newborn promptly after delivery to reduce the risk of HIV transmission, as HIV can be present in blood and other bodily fluids. Proper cleansing helps minimize the risk of exposure.

D. Breastfeeding is contraindicated for mothers with HIV because HIV can be transmitted through breast milk. Instead, formula feeding is recommended to prevent transmission.

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Correct Answer is C

Explanation

make a loud noise above the newborn. The Moro reflex is elicited by making a loud noise above the newborn or allowing the newborn's head to drop slightly. The newborn will respond by extending and abducting the arms, and then bringing them back to the body, followed by crying. This reflex should be present in a term newborn and is an indication of neurological health.

A. Blood pressure 136/88 mm Hg B. Urinary output 120 mL in 2 hr C. Respiratory rate 10/min D. Moderate fetal heart rate variability

Correct Answer is C

Explanation

The nurse should report a respiratory rate of 10/min to the provider following the administration of butorphanol IV bolus. Butorphanol is an opioid agonist-antagonist analgesic that can cause respiratory depression as a side effect. Therefore, it is important to monitor the client's respiratory rate and depth closely after administration of the medication. A respiratory rate of 10/min is significantly lower than the normal range of 1220/min, and may indicate respiratory depression. The nurse should also monitor the client's blood pressure, urinary output, and fetal heart rate for any changes, but these findings are not necessarily indicative of a complication following the administration of butorphanol.

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A nurse on the labor and delivery unit is planning care for a client who has human immunodeficiency virus (HIV). Which of the following is an appropriate action for the nurse to take following the birth of the newborn?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing the reflexes of a term newborn. After placing the newborn in the supine position, which of the following methods should the nurse use to elicit the Moro reflex?

Correct Answer is C

Explanation

A nurse is caring for a client who is in active labor. The nurse administers butorphanol IV bolus for pain. Which of the following findings should the nurse report to the provider following this medication?

Correct Answer is C

Explanation

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