Nokea
A client at 40-weeks gestation is admitted in active labor, and laboratory findings indicate that she is HIV positive. Which actions should the nurse plan to perform? (Select all that apply.)
- A. Place client in a negative pressure room
- B. Implement droplet precautions
- C. Encourage the mother to bottle-feed
- D. Give antiviral medication intravenously
- E. Use standard precautions
Correct Answer: C,D,E
Rationale: HIV is transmitted through blood, body fluids, or breast milk, not air or droplets. Bottle-feeding (C) prevents transmission via breast milk, IV antiviral medication (D) reduces perinatal transmission, and standard precautions (E) are sufficient for infection control.
You may also like to solve these questions
A client is admitted to the postpartum unit and tells the nurse she had rheumatic fever as a child, which resulted in some 'heart damage.' The nurse knows that this client is at particular risk for developing heart failure during the immediate postpartum period. Based on this client's history, which nursing problem has the highest priority?
- A. Sleep deprivation.
- B. Fluid volume excess
- C. Nausea and vomiting
- D. Risk for infection.
Correct Answer: B
Rationale: Heart damage from rheumatic fever increases the risk of heart failure, particularly postpartum due to fluid shifts. Managing fluid volume excess is the priority.
A father watching the admission of his newborn to the nursery notices that eye ointment is placed in the infant's eyes. He asks the nurse what is the purpose of the ointment. The nurse would be correct in stating that the purpose for using the ointment is to
- A. dilate the pupil so the red reflex can be visualized
- B. prevent herpes infection.
- C. prevent eye infections
- D. clear the infant's vision
Correct Answer: C
Rationale: Antibiotic eye ointment, typically erythromycin, is applied to prevent neonatal conjunctivitis, particularly from gonorrhea or chlamydia, which can be transmitted during birth.
The nurse is caring for a client who delivered 6 hours ago. Assessment findings reveal a boggy uterus that is displaced above and to the right of the umbilicus. Which action should the nurse take?
- A. Encourage voiding
- B. Notify healthcare provider
- C. Inspect the perineal pad
- D. Monitor vital signs
Correct Answer: A
Rationale: A boggy uterus displaced above and to the right of the umbilicus often indicates a distended bladder, which can prevent proper uterine contraction. Encouraging voiding addresses this issue, helping the uterus return to its normal position and firm up.
A young woman who underwent a liver transplant one year ago tells the clinic nurse that she would like to start a family. How should the nurse intervene?
- A. Provide information about the high risk nature of her pregnancy
- B. Explain the benefits of a five-year post-transplant waiting period
- C. Gently remind the client that anti-rejection drugs cause sterility
- D. Determine if the client is considering options for adopting a child
Correct Answer: B
Rationale: A five-year post-transplant waiting period is recommended to stabilize health and ensure the transplanted organ functions well before the stress of pregnancy.
The nurse is preparing to administer magnesium sulfate to a laboring client whose blood pressure has increased from 110/60 mmHg to 140/90 mmHg Which nursing protocol has the highest priority?
- A. Insert a Foley catheter with a urimeter to monitor hourly output
- B. Have calcium gluconate immediately available
- C. Provide a quiet environment with subdued lighting.
- D. Assess deep tendon reflexes (DTRS) every 4 hours.
Correct Answer: B
Rationale: Magnesium sulfate toxicity can cause neuromuscular blockade, making calcium gluconate, the antidote, critical to have immediately available in case of toxicity signs like loss of deep tendon reflexes.