A newborn is delivered by cesarean section to a mother who is HIV-positive.
The mother received antiretroviral therapy during pregnancy.
Which intervention should the nurse implement?
Give zidovudine 6 to 12 hours after birth.
Administer antibiotics for 7 to 10 days.
Delay the initial bath for 1 to 2 days.
Encourage breastfeeding every 2 to 3 hours.
The Correct Answer is A
Choice A rationale
Giving zidovudine 6 to 12 hours after birth is crucial as it helps prevent mother-to-child transmission of HIV. Early administration of antiretroviral medication reduces the risk of the newborn acquiring HIV significantly.
Choice B rationale
Administering antibiotics for 7 to 10 days is not standard practice for newborns of HIV-positive mothers unless there is an indication of infection. The primary intervention is antiretroviral therapy.
Choice C rationale
Delaying the initial bath for 1 to 2 days is not standard practice for preventing HIV transmission. It is important to bathe the newborn shortly after birth to remove any potential HIV-containing fluids.
Choice D rationale
Encouraging breastfeeding every 2 to 3 hours is not advised for HIV-positive mothers as HIV can be transmitted through breast milk. Alternatives such as formula feeding are recommended to prevent transmission. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["2.3"]
Explanation
Step 1 is to convert the child's weight from pounds to kilograms. 16 pounds ÷ 2.2 = 7.3 kg.
Step 2 is to calculate the total daily dose in mg. 25 mg/kg × 7.3 kg = 182.5 mg.
Step 3 is to determine the dose per administration, divided by 2 since the dose is given every 12 hours. 182.5 mg ÷ 2 = 91.25 mg.
Step 4 is to convert the dose from mg to mL using the concentration of the medication. 91.25 mg ÷ (200 mg/5 mL) = 91.25 ÷ 40 = 2.3 mL per dose. The answer is 2.3 mL.
Correct Answer is C
Explanation
Choice A rationale
Diaphragmatic respirations are a normal breathing pattern and do not indicate respiratory distress. In fact, diaphragmatic breathing can be beneficial for patients with respiratory conditions as it helps to maximize lung expansion and improve oxygenation. Therefore, this finding is not indicative of acute respiratory distress in a child with asthma.
Choice B rationale
Bilateral bronchial breath sounds are usually heard over the large airways, such as the trachea and the main bronchi, and are not typically associated with acute respiratory distress. Wheezing or diminished breath sounds would be more indicative of airway obstruction and respiratory distress in a child with asthma.
Choice C rationale
Flaring of the nares is a sign of increased respiratory effort and is commonly seen in children with acute respiratory distress. This indicates that the child is struggling to breathe and is using additional muscles to help with respiration, which is a concerning sign that requires immediate attention.
Choice D rationale
A resting respiratory rate of 35 breaths per minute is elevated for a 3-year-old child but is not the most specific sign of acute respiratory distress. While tachypnea can indicate respiratory distress, other signs, such as nasal flaring, retractions, and cyanosis, are more specific indicators of the severity of the child's condition. .
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