A nurse on the labor 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?
Initiate contact precautions for the newborn.
Administer IV antibiotics to the newborn.
Cleanse the newborn immediately after delivery.
Encourage the mother to breastfeed her newborn.
The Correct Answer is C
A. While contact precautions may be necessary for certain infections, they are not specifically required for an HIV-positive mother’s newborn if the infant is not infected. The newborn’s HIV status should be confirmed through testing.
B. IV antibiotics are not routinely administered to newborns of HIV-positive mothers unless there is a specific indication for infection prevention or treatment.
C. It is crucial to clean the newborn promptly after delivery to reduce the risk of HIV transmission, as HIV can be present in blood and other bodily fluids. Proper cleansing helps minimize the risk of exposure.
D. Breastfeeding is contraindicated for mothers with HIV because HIV can be transmitted through breast milk. Instead, formula feeding is recommended to prevent transmission.
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Related Questions
Correct Answer is D
Explanation
This
suggests that the nurse should assess the newborn's latch while breastfeeding. Sore nipples are a common concern among breastfeeding mothers, and the most common cause is an improper latch. The nurse should ensure that the baby is latching on correctly and not causing trauma to the mother's nipples. A proper latch involves the baby taking in a good portion of the areola and not just the nipple. Assessing the newborn's latch can help identify any issues with the baby's mouth or tongue that may be causing difficulty latching on. If the baby is not latching correctly, the nurse can provide education and support to help the mother correct the issue. Offering supplemental formula between feedings (choice A) is not recommended as it can decrease the frequency of breastfeeding and reduce the stimulation for milk production, leading to decreased milk supply. Instructing the client to wait 4 hours between daytime feedings (choice C) is not recommended as it can decrease milk production and lead to inadequate nutrition for the newborn.
Correct Answer is B
Explanation
Uterine atony is a condition in which the uterus is not contracting effectively following delivery, which can lead to postpartum hemorrhage. Oxytocin is the first-line medication used to stimulate uterine contractions, but if the client fails to respond to oxytocin, the nurse should anticipate the use of a second-line medication, such as methylergonovine. Terbutaline is a tocolytic medication used to stop contractions, not stimulate them. Betamethasone is a corticosteroid used to promote fetal lung maturity before preterm delivery. Hydralazine is a vasodilator used to treat hypertension, not uterine atony.
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