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 foetal 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 birth.

Answer and Explanation

The Correct Answer is C

Pregnant clients with HIV require comprehensive care during pregnancy, delivery, and postpartum periods to prevent transmission of HIV to the newborn. Bathing the newborn before initiating skin-to-skin contact is a recommended action to reduce the risk of HIV transmission from mother to child. This practice helps to remove any maternal blood or other bodily ﬂuids from the newborn's skin, which may contain the virus. Therefore, the nurse should instruct the client to bathe the newborn before initiating skin-to-skin contact.

Antiretroviral medications are usually continued throughout pregnancy and during labor and delivery to decrease the risk of transmission to the newborn. Therefore, the nurse should not instruct the client to stop taking antiretroviral medications at 32 weeks of gestation, as mentioned in option a.

Fetal scalp electrode is a device that ataches to the baby's scalp to monitor the fetal heart rate. This device can cause small cuts or abrasions on the baby's scalp, which may increase the risk of HIV transmission.

Therefore, its use should be avoided in clients with HIV. Therefore, option b is not a recommended action.

Administering pneumococcal immunization to the newborn within 4 hours following birth is not a recommended action in the plan of care for a client who is pregnant and has HIV. Pneumococcal immunization is not indicated for newborns immediately after birth. Therefore, option d is not a recommended action.

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Correct Answer is A

Explanation

Fundal height is measured from the top of the pubic bone to the top of the uterus and is used to assess fetal growth. A fundal height measurement that is larger than expected for gestational age may indicate a problem such as macrosomia (a larger than average baby), which can be a complication of gestational diabetes. The nurse should report this finding to the provider for further evaluation.

A. Turn the client onto their side B. Initiate an amnioinfusion for the client C. Administer naloxone to the client D. Monitor the client’s blood pressure every 15 min

Correct Answer is A

Explanation

A common side eﬀect of epidural anaesthesia is a drop in blood pressure. Turning the client onto their side can help improve blood ﬂow to the uterus and baby and may help raise the mother’s blood pressure.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is at 32 weeks of gestation and has gestational diabetes mellitus. Which of the following findings should the nurse report to the provider?

Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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