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 D

Explanation

After giving birth, a woman's body undergoes many changes, including changes in the size and shape of the vagina. It is essential to have the correct size of diaphragm to ensure its eﬀectiveness.

Therefore, the nurse should instruct the client to have a provider refit her for a new diaphragm.

Option a is incorrect because the diaphragm should be cleaned with warm water and mild soap, not an oil- based vaginal lubricant.

Option b is incorrect because the diaphragm should be removed no sooner than 6 hours after intercourse but should not be left in place for more than 24 hours.

Option c is incorrect because oil-based vaginal lubricants can damage latex diaphragms, reducing their eﬀectiveness as a contraceptive method. Water-based lubricants should be used instead.

A. Decrease in frequency of contractions B. BP 150/100 mm Hg C. Absent deep tendon reﬂexes D. Urinary output 35 mL/hr

Correct Answer is C

Explanation

Absent deep tendon reﬂexes are a sign of magnesium toxicity, which can occur with high levels of magnesium in the bloodstream. This can be a serious complication that requires immediate atention from the provider.

Option A, a decrease in frequency of contractions, is actually a desired eﬀect of magnesium sulfate in the management of preterm labor. It is not a cause for concern.

Option B, a blood pressure reading of 150/100 mm Hg, is high, but it is not necessarily related to the administration of magnesium sulfate. However, it should still be reported to the provider for appropriate management.

Option D, a urinary output of 35 mL/hr, is below the normal range but it may still be within an acceptable range for a client receiving magnesium sulfate. The provider should be notified if urinary output continues to decrease or if it falls below a certain threshold.

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 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?

Correct Answer is D

Explanation

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?

Correct Answer is C

Explanation

A nurse is discussing risk factors of postpartum haemorrhage with a newly licensed nurse. Which of the following conditions is a risk factor for postpartum haemorrhage that the nurse should include in the teaching?

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 teaching a client and her partner about the technique of counterpressure during labor. Which of the following statements by the nurse is appropriate?

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?

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?

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 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?

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?