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 A

Explanation

Choice A rationale

Being 37-weeks, 1-day gestation is considered term. This timing indicates the fetus is likely mature and ready for birth, which reduces the risk of complications compared to preterm delivery. However, early-term delivery can still have some associated risks, such as respiratory issues or feeding difficulties.

Choice B rationale

A pain rating of 5 during contractions is within the expected range during active labor. Pain management is an important aspect of labor care, but it does not inherently increase or decrease the risk of complications.

Choice C rationale

The vaginal exam findings of 4 cm dilation, 50% effacement, and -3 station indicate early labor progression. However, the negative station suggests the fetus is still high in the pelvis, which could pose a risk if labor stalls or if there is cephalopelvic disproportion.

Choice D rationale

Contractions every 3 to 4 minutes are consistent with active labor. Regular and moderate contractions are expected and necessary for labor to progress. This data point alone does not increase the risk for complications.

Choice E rationale

An A- blood type with Rh(D) immune globulin received at 28 weeks is managed appropriately to prevent Rh sensitization. Rh(D) immune globulin reduces the risk of hemolytic disease of the fetus and newborn in subsequent pregnancies, making it an important preventative measure but not a current risk factor. .

A. Respiratory rate of 50 breaths per minute. B. Shallow and irregular respirations. C. Flaring of the nares. D. Abdominal breathing with synchronous chest movement.

Correct Answer is C

Explanation

Choice A rationale

A respiratory rate of 50 breaths per minute is within the normal range for a newborn and does not indicate respiratory distress. Newborns typically have a higher respiratory rate than adults, and this is considered normal.

Choice B rationale

Shallow and irregular respirations can occur in healthy newborns and do not necessarily indicate respiratory distress. It is important to monitor for additional signs of distress before making a definitive assessment.

Choice C rationale

Flaring of the nares is a sign of respiratory distress in newborns as it indicates increased effort to breathe. This symptom is associated with conditions such as respiratory distress syndrome and requires prompt medical evaluation and intervention.

Choice D rationale

Abdominal breathing with synchronous chest movement is normal for newborns as their diaphragm is the primary muscle for respiration. This type of breathing pattern does not indicate respiratory distress and is expected in healthy newborns.

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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?

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

The nurse is performing a newborn assessment.Which symptom, if present in a newborn, would indicate respiratory distress?

Correct Answer is C

Explanation

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A client who suspects she is pregnant tells the nurse she has a peptic ulcer that is being treated with misoprostol, a synthetic prostaglandin E drug.How should the nurse respond?

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?