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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C, "Increased muscle weakness." The nurse should instruct the client to report increased muscle weakness, as this can indicate toxicity from magnesium sulfate. Increased fetal movement is not an indication of toxicity from magnesium sulfate. Increased respiratory rate is a common side effect of magnesium sulfate and does not require intervention unless it is significantly increased. Increased urinary output is a normal effect of magnesium sulfate and does not require intervention.
Correct Answer is D
Explanation
The correct answer is choice D, Sharp pelvic pain. An ectopic pregnancy occurs when a fertilized egg implants outside of the uterus, most commonly in the fallopian tube. Sharp pelvic pain is a classic sign of an ectopic pregnancy, as the developing embryo can cause the tube to rupture or stretch, leading to pain. A scaphoid abdomen, elevated blood pressure, and bright red vaginal discharge are not typical manifestations of an ectopic pregnancy. 
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