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 B
Explanation
Perform vibroacoustic stimulation. A nonstress test is a prenatal test that is used to evaluate fetal well-being. It involves monitoring the fetal heart rate in response to fetal movement. The absence of accelerations for 20 minutes may indicate fetal distress. Vibroacoustic stimulation is a technique used to elicit fetal movement and accelerate the fetal heart rate. It involves applying a vibrating device to the mother's abdomen.
Correct Answer is C
Explanation
A. Discomfort in the lower back (sacral area) is common during labor, particularly during contractions. This is not an unusual finding that would require immediate reassessment.
B. Contractions lasting between 45 to 60 seconds are typical during the active phase of labor. This duration of contractions is expected as labor progresses, and does not require immediate reassessment.
C. This sensation can indicate that the fetus has descended into the birth canal and may be a sign that the client is entering the second stage of labor, or is close to delivery. This requires immediate reassessment by the nurse to check for full cervical dilation and fetal descent.
D. Emotional excitement and changes in skin temperature are typical responses during labor due to the physiological and emotional aspects of childbirth. This does not indicate the need for immediate reassessment.
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