A full-term infant is admitted to the newborn nursery 2 hours after delivery.The delivery record indicates the mother is positive for human immunodeficiency virus (HIV) and received zidovudine intravenously during labor.
Which action should the nurse implement?

Obtain consent for the Hepatitis B vaccine.

Collect a venous specimen for serum glucose level.

Assess for the presence of the Moro reflex.

Ensure that zidovudine is given within 6 hours after birth.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Obtaining consent for the Hepatitis B vaccine is a necessary step in the newborn's care, but it is not the immediate priority for a newborn exposed to HIV. The focus should be on preventing HIV transmission from mother to child.

Choice B rationale

Collecting a venous specimen for serum glucose level is important for assessing the newborn's metabolic status, but it does not directly address the immediate need to reduce the risk of HIV transmission.

Choice C rationale

Assessing for the presence of the Moro reflex is part of a routine newborn examination and is important for evaluating the neurological status of the newborn. However, it does not address the immediate priority of HIV prophylaxis.

Choice D rationale

Ensuring that zidovudine is given within 6 hours after birth is critical for reducing the risk of mother-to-child transmission of HIV. Early administration of antiretroviral medication is essential to prevent viral replication and transmission to the newborn.

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Correct Answer is D

Explanation

Assessing vital signs is important but not the most immediate action for heavy postpartum bleeding. It provides information about the client's current status but does not address the bleeding directly.

Choice B rationale

Increasing the IV infusion rate can help manage blood loss by maintaining blood volume, but it is not the first action to take when managing postpartum hemorrhage.

Choice C rationale

Notifying the healthcare provider is important but secondary to addressing the immediate cause of the bleeding. The provider will need information about the client's status and the actions taken to manage the situation.

Choice D rationale

Massaging the fundus is the most immediate and effective action to reduce postpartum hemorrhage. It stimulates uterine contractions, which helps to clamp down on the blood vessels and stop the bleeding.

A. Administer oxygen. B. Check cervical dilation. C. Start an intravenous fluid bolus. D. Prepare for immediate delivery.

Correct Answer is B

Explanation

Choice A rationale

Administering oxygen would not be the priority as the fetal heart rate is normal and there are no abnormal fetal movements or signs of distress. Oxygen administration is typically reserved for cases where there is evidence of fetal hypoxia or distress.

Choice B rationale

Checking cervical dilation is essential as it provides critical information about the progress of labor and helps in determining the next steps in management. It ensures that the labor is progressing appropriately and identifies if there is a need for any medical interventions.

Choice C rationale

Starting an intravenous fluid bolus would not be the first action in this scenario as the client does not show signs of dehydration or hypotension. Fluid bolus is generally reserved for cases where there is evidence of hypovolemia or to support hemodynamic stability.

Choice D rationale

Preparing for immediate delivery is not necessary at this stage as there are no signs of fetal distress or urgent complications. The client is only 37 weeks gestation and regular assessment is crucial to ensure timely and appropriate interventions without premature actions.

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A full-term infant is admitted to the newborn nursery 2 hours after delivery.The delivery record indicates the mother is positive for human immunodeficiency virus (HIV) and received zidovudine intravenously during labor. Which action should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a postpartum client who delivered 5 hours ago, and has saturated a perineal pad with clots within the last 15 minutes.Which action is most important for the nurse to implement?

Correct Answer is D

Explanation

A client at 37 weeks gestation presents with contractions every 3 to 4 minutes, lasting 60 seconds.The fetal heart rate is noted to be 140 bpm, and no abnormal fetal movements are observed.The client reports no pain and normal laboratory results.Which action should the nurse implement first?

Correct Answer is B

Explanation

A client at 37 weeks gestation presents to labor and delivery with contractions every 2 minutes.The nurse observes several shallow, small vesicles on her pubis, labia, and perineum.The nurse should recognize the client is exhibiting symptoms of which condition?

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A full-term infant is admitted to the newborn nursery 2 hours after delivery.The delivery record indicates the mother is positive for human immunodeficiency virus (HIV) and received zidovudine intravenously during labor.
Which action should the nurse implement?