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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A. A midline episiotomy is a surgical incision made in the perineal area during childbirth. It is recognized as a risk factor for postpartum infection due to the possibility of bacterial contamination during and after delivery. Proper care and monitoring are essential to prevent infection in the site of the incision.

B.meconium-stained fluid, is not typically a risk factor for maternal infection; it is more a concern for the infant's health if aspirated.

C.gestational hypertension, affects blood pressure during pregnancy but does not directly increase the risk of postpartum infection.

D.placenta previa, is a condition where the placenta covers the cervix, which can lead to bleeding but not infection. Therefore, among the given options, a midline episiotomy is the factor that most significantly places the postpartum client at risk for an infection.

A. Macrosomia B. Cataracts C. Urinary tract infection D. Hearing loss

Correct Answer is D

Explanation

Cytomegalovirus (CMV) is a common virus that can cause serious health problems in newborns if the mother acquires a primary infection during pregnancy and passes the virus to the developing fetus. CMV can be transmited transplacentally or during delivery through contact with infected body ﬂuids.

Newborns who acquire CMV transplacentally may exhibit a range of symptoms, including jaundice, hepatosplenomegaly, thrombocytopenia, microcephaly, and hearing loss. Of the options listed, only hearing loss is consistent with a congenital CMV infection.

Macrosomia (option a) refers to a condition in which a baby is born larger than average for gestational age. It is not typically associated with a congenital CMV infection.

Cataracts (option b) are a clouding of the lens of the eye and are not typically associated with a congenital CMV infection.

Urinary tract infection (option c) is a possible complication of a congenital CMV infection, but hearing loss is a more common and specific finding.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 reviewing the electronic medical record of a postpartum client. The nurse should identify that which of the following factors places the client at risk for an infection?

Correct Answer is A

Explanation

A nurse is assessing a newborn whose mother had a primary cytomegalovirus (CMV) infection during pregnancy. The newborn acquired CMV transplacentally. Which of the following findings should the nurse expect the newborn to exhibit?

Correct Answer is D

Explanation

A nurse is reviewing the chart of a client who is 2 days postpartum following a vaginal delivery and reports constipation. Which of the following findings should the nurse identify as a contraindication to the use of a suppository?

A nurse is performing an assessment of a newborn’s Babinski reﬂex. Which of the following findings should the nurse expect?

A nurse is providing teaching to a client who is 2 days postpartum and wants to continue using her diaphragm for contraception. Which of the following instructions should the nurse include?

A nurse is assessing a client who is at 32 weeks of gestation and is receiving magnesium sulphate via continuous IV infusion. Which of the following findings should the nurse report to the provider?

A nurse in a newborn nursery is receiving change-of-shift report for four newborns. Which of the following newborns should the nurse assess first?

A nurse is caring for a client who is at 30 weeks of gestation and receiving magnesium sulfate for preeclampsia. The nurse should recognize which of the following manifestations as an adverse reaction to the medication?

A nurse is caring for a client who has pregestational diabetes mellitus. Which of the following clinical findings should indicate to the nurse that the client has hyperglycemia?

A nurse is caring for a client who is postpartum and experiencing hypovolemic shock. Which of the following findings should the nurse expect?