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

The correct answer is choice C, "Maintain scheduled mealtimes for yourself." The nurse should instruct the postpartum client with type 1 diabetes mellitus and who is breastfeeding her newborn to maintain scheduled mealtimes for herself to ensure stable blood glucose levels. The client should also monitor her blood glucose levels more frequently, aiming to maintain a level between 60 to 99 mg/dL before meals and less than 120 mg/dL one hour after meals. Breastfeeding can cause hypoglycemia, so the client should have a source of glucose nearby while nursing. The client should consume a balanced diet, including fruits, vegetables, whole grains, lean proteins, and low-fat dairy, and aim to consume at least 175 g of carbohydrates per day.

A. Overlapping of the cranial bones B. Small, distended white sebaceous glands on the face C. Bluish discoloration of the hands and feet D. Forward and lateral positioning of the ears

Correct Answer is D

Explanation

A.Cranial bone overlap (molding) is common after vaginal delivery due to compression during birth. It typically resolves within a few days and does not require urgent intervention.

B.These are called milia, which are harmless and expected in newborns. They resolve spontaneously without treatment.

C.This is known as acrocyanosis, a normal finding in newborns during the first 24–48 hours of life due to immature circulation. It is not a cause for concern unless central cyanosis is present (e.g., lips or mucous membranes are blue).

D.Abnormal positioning of the ears (e.g., low-set or forward and lateral) can be a sign of congenital anomalies, particularly renal abnormalities or chromosomal syndromes such as Trisomy 21 (Down syndrome) or Trisomy 18. Because these may indicate serious underlying systemic conditions, the nurse must report this finding promptly to initiate further evaluation and possibly diagnostic testing (e.g., renal ultrasound or genetic consultation).

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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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Correct Answer is D

Explanation

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