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 D

Explanation

The correct answer is choice D. "The nurse should measure the newborn's muscle tone when assigning an Apgar score." components of the Apgar score:

Component	0 Points	1 Point	2 Points
Heart Rate	Absent	<100 bpm	>100 bpm
Respiratory Effort	Absent	Slow, irregular	Good, crying
Muscle Tone	Flaccid	Some flexion	Active motion
Reflex Irritability	No response	Grimace	Vigorous cry
Color	Blue, pale	Body pink, extremities blue	Completely pink

The score for each component is summed up to a maximum score of 10, with 10 indicating the healthiest newborn. The NRP guidelines emphasize that resuscitation efforts should be initiated immediately after delivery, regardless of the Apgar score, thus choice C is wrong.

A. Tap the newborn's forehead with a finger. B. Turn the newborn's head to one side. C. Make a loud noise above the newborn. D. Touch the newborn's cheek with a finger.

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.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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