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.
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Related Questions
Correct Answer is A
Explanation
A. Apply a cap to the newborn's head: This is an appropriate intervention to conserve heat in a mildly hypothermic newborn. It is a standard practice to maintain thermal neutrality, especially in the first hours after birth.
B. Give the newborn a warm bath: Bathing is not appropriate for a newborn with a low temperature. Bathing could worsen heat loss and further lower the newborn's body temperature.
C. Reposition the newborn: While repositioning may improve comfort or support effective respiration, it does not directly address the low temperature.
D. Obtain an oxygen saturation level: The respiratory rate (50/min) and heart rate (130/min) are within the normal range for a newborn. Unless other signs of respiratory distress or cyanosis are present, this action is unnecessary.
Correct Answer is A
Explanation
. The nurse should report cervical dilation to the provider as an indication of an imminent spontaneous abortion. Cervical dilation is a sign of cervical incompetence and can lead to spontaneous abortion. Scant, bright red spotting is a common finding in early pregnancy and may not indicate an imminent spontaneous abortion. Slight abdominal cramps can also be a normal finding in early pregnancy. Elevated hcG levels can indicate a viable pregnancy.
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