A nurse in the labour 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?

Administer IV antibiotics to the newborn.

Encourage the mother to breastfeed her newborn.

Cleanse the newborn immediately after delivery.

Initiate contact precautions for the newborn.

Answer and Explanation

The Correct Answer is C

The correct answer is c. Cleanse the newborn immediately after delivery. This is because cleansing the newborn can reduce the risk of HIV transmission through exposure to maternal blood or fluids. The other options are not appropriate for the following reasons:

a. Administer IV antibiotics to the newborn. This is not necessary unless the newborn has signs of infection or sepsis. Antibiotics do not prevent or treat HIV infection.
b. Encourage the mother to breastfeed her newborn. This is contraindicated for mothers with HIV, as breastfeeding can transmit the virus to the infant. Mothers with HIV should avoid breastfeeding and use formula or donor milk instead.
d. Initiate contact precautions for the newborn. This is not required for newborns exposed to HIV, as HIV is not transmitted by casual contact. Standard precautions are sufficient to prevent the spread of HIV and other bloodborne pathogens.

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Correct Answer is C

Explanation

The correct answer is choice c. Heart rate 72/min.

Choice A rationale:

A blood pressure of 80/50 mm Hg is within the normal range for a full-term newborn.

Choice B rationale:

A respiratory rate of 55/min is also within the normal range for a newborn, which typically ranges from 30 to 60 breaths per minute.

Choice C rationale:

A heart rate of 72/min is significantly lower than the normal range for a newborn, which is typically between 120 to 160 beats per minute. This bradycardia should be reported to the provider as it may indicate an underlying issue.

Choice D rationale:

A temperature of 36.5°C (97.7°F) is within the normal range for a newborn, which is generally between 36.5°C to 37.5°C (97.7°F to 99.5°F).

A. Blood pressure 136/88 mm Hg. B. Moderate fetal heart rate variability. C. Respiratory rate 100/min. D. Urinary output 120 mL in 2 hr.

Correct Answer is C

Explanation

Choice A rationale:

Blood pressure of 136/88 mm Hg should be monitored, but it is not a finding that the nurse needs to urgently report to the provider following the administration of butorphanol. The blood pressure reading is slightly elevated but might be attributed to pain or anxiety during labor.

Choice B rationale:

Moderate fetal heart rate variability is a reassuring sign of fetal well-being and is an expected finding during labor. It does not require immediate reporting to the provider.

Choice C rationale:

Respiratory rate of 100/min is significantly increased and should be reported to the provider following the administration of butorphanol. Respiratory depression is a potential side effect of opioids like butorphanol, and a respiratory rate of 100/min raises concern for potential respiratory compromise.

Choice D rationale:

Urinary output of 120 mL in 2 hours is an acceptable finding during labor and does not require immediate reporting to the provider. Adequate urinary output varies, but generally, 30 mL/hour is considered acceptable during labor.

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A nurse in the labour 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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a full-term newborn. Which of the following findings should the nurse report to the provider?

Correct Answer is C

Explanation

A nurse is caring for a client who is in active labor. The nurse administers butorphanol IV bolus for pain. Which of the following findings should the nurse report to the provider following this medication?

Correct Answer is C

Explanation

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