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.

Answer and Explanation

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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Correct Answer is C

Explanation

The correct answer is choice C, "Maintain scheduled mealtimes for yourself." The nurse should instruct the postpartum client with type 1 diabetes mellitus and who is breastfeeding her newborn to maintain scheduled mealtimes for herself to ensure stable blood glucose levels. The client should also monitor her blood glucose levels more frequently, aiming to maintain a level between 60 to 99 mg/dL before meals and less than 120 mg/dL one hour after meals. Breastfeeding can cause hypoglycemia, so the client should have a source of glucose nearby while nursing. The client should consume a balanced diet, including fruits, vegetables, whole grains, lean proteins, and low-fat dairy, and aim to consume at least 175 g of carbohydrates per day.

A. Increased fetal movement B. Increased respiratory rate C. Increased muscle weakness D. Increased urinary output

Correct Answer is C

Explanation

The correct answer is choice C, "Increased muscle weakness." The nurse should instruct the client to report increased muscle weakness, as this can indicate toxicity from magnesium sulfate. Increased fetal movement is not an indication of toxicity from magnesium sulfate. Increased respiratory rate is a common side effect of magnesium sulfate and does not require intervention unless it is significantly increased. Increased urinary output is a normal effect of magnesium sulfate and does not require intervention.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to a postpartum client who has type 1 diabetes mellitus and is breastfeeding her newborn. Which of the following instructions should the nurse give the client?

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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