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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Right upper quadrant: This is not the correct location for hearing the fetal heart rate in the LOA position, as it is on the opposite side and higher than expected.
B. Left upper quadrant: The fetal heart rate in the LOA position is heard below, not above, the maternal umbilicus.
C. Left lower quadrant: The PMI of the fetal heart rate is best heard in the left lower quadrant when the fetus is in the left occipitoanterior position, as the fetal back (closest to the heart) is located on the left side and positioned anteriorly.
D. Right lower quadrant: This site is appropriate for a right occipitoanterior (ROA) fetal position, not LOA.
Correct Answer is B
Explanation
The correct answer is choice B. Facial petechiae are a clinical finding that can occur in newborns who had a nuchal cord during delivery. The nuchal cord occurs when the umbilical cord becomes wrapped around the fetal neck one or more times. Erythema toxicum is a common, benign rash that appears as small, firm, yellow, or white papules surrounded by a red halo. Periauricular papillomas and telangiectatic nevi are not associated with the nuchal cord.
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