A nurse is planning care for a client who is pregnant and has HIV. Which of the following actions should the nurse include in the plan of care?
Instruct the client to stop taking the antiretroviral medications at 32 weeks of gestation.
Use a fetal scalp electrode during labor and delivery.
Bathe the newborn before initiating skin-to-skin contact.
Administer a pneumococcal immunization to the newborn within 4 hr following
The Correct Answer is C
The purpose of bathing the newborn before initiating skin-to-skin contact is to decrease the risk of transmission of the virus from the mother to the newborn. Instructing the client to stop taking the antiretroviral medications at 32 weeks of gestation is incorrect as these medications should be taken throughout pregnancy to decrease the risk of transmission to the fetus.
Using a fetal scalp electrode during labor and delivery is also not an appropriate action as it increases the risk of transmission of the virus to the newborn. Administering a pneumococcal immunization to the newborn within 4 hours following birth is not specific to HIV positive newborns and is not related to preventing transmission of the virus.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Epidural analgesia during labor can cause temporary bladder dysfunction, which may result in an inability to void. This is due to the epidural medication affecting the nerves that control the bladder. If the client is unable to void, it can lead to bladder distention, which can be uncomfortable for the client and increase the risk of infection.
Tingling in her legs, abdominal cramps, and itching are common side effects of epidural analgesia, and can be addressed after the client's inability to void is addressed. The nurse can provide the client with education on these side effects and reassurance that they are typically temporary and should resolve on their own.
Correct Answer is D
Explanation
Cytomegalovirus (CMV) is a viral infection that can cause serious health problems for newborns if acquired in utero. Some newborns may appear asymptomatic at birth but later develop complications such as hearing loss, intellectual disability, and vision problems. The virus can be transmitted through bodily fluids such as saliva, urine, and breast milk, and can be especially dangerous for premature infants or those with weakened immune systems. While macrosomia (large body size) and urinary tract infections are possible complications in newborns, they are not typically associated with CMV. Cataracts may also occur in infants with congenital CMV, but hearing loss is a more common complication.
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