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A newborn is delivered by cesarean section to a mother who is HIV-positive. The mother received antiretroviral therapy during pregnancy. Which intervention should the nurse implement?
- A. Encourage breastfeeding every 2 to 3 hours.
- B. Give zidovudine 6 to 12 hours after birth.
- C. Administer antibiotics for 7 to 10 days.
- D. Delay the initial bath for 1 to 2 days.
Correct Answer: B
Rationale: Zidovudine within 6-12 hours reduces HIV transmission risk in newborns of HIV-positive mothers, unlike breastfeeding, which is contraindicated, or antibiotics and delayed bathing, which are irrelevant.
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A client who delivered vaginally 18 hours ago develops a slight fever. The client's delivery record shows spontaneous rupture of membranes (SROM) for 36 hours prior to delivery and labor lasting 24 hours. An epidural was placed during labor, and she experienced a third-degree perineal laceration. The nurse should recognize which information poses the greatest risk for developing postpartum endometritis?
- A. SROM for 36 hours.
- B. Labor lasting for 24 hours.
- C. Third-degree perineal laceration.
- D. Epidural anesthesia.
Correct Answer: A
Rationale: Prolonged SROM significantly increases the risk of postpartum endometritis due to extended exposure to pathogens.
The nurse knows that hydralazine, while magnesium sulfate will help prevent seizures, will help decrease blood pressure thus?
- A. Improving kidney function.
- B. Supporting liver health.
- C. Preventing arrhythmias.
- D. Lowering cholesterol levels.
Correct Answer: A
Rationale: Hydralazine's vasodilation lowers blood pressure, improving renal perfusion and kidney function, critical in preeclampsia management.
A primipara presents to the perinatal unit describing rupture of the membranes (ROM) occurring 12 hours prior to coming to the hospital. An oxytocin infusion is begun, and 8 hours later the client's contractions are irregular and mild. Based on this data, the nurse plans to monitor which sign more frequently than for the average laboring client?
- A. Color of amniotic fluid.
- B. Maternal temperature.
- C. Deep tendon reflexes.
- D. Maternal blood pressure.
Correct Answer: B
Rationale: Prolonged ROM increases infection risk, necessitating frequent maternal temperature monitoring to detect chorioamnionitis early.
During the admission of a newborn, the nurse identifies a localized swelling that does not cross the suture line on the posterior area of the parietal bone. Which action should the nurse implement?
- A. Apply direct pressure to the caput succedaneum.
- B. Submit a request for a STAT Computerized Tomography (CT) scan of the head.
- C. Notify the pediatrician of the cephalhematoma.
- D. Assess neurological vital signs every 4 hours.
Correct Answer: C
Rationale: A cephalhematoma, not crossing suture lines, requires pediatrician notification to monitor for complications like jaundice, unlike caput succedaneum or unnecessary CT scans.
A client who is positive for Neisseria gonorrhoeae vaginally delivered a newborn. Which medication should the nurse administer to the newborn?
- A. Erythromycin ointment.
- B. Neomycin ointment.
- C. Tetracaine eye drops.
- D. Latanoprost eye drops.
Correct Answer: A
Rationale: Erythromycin ointment is the standard prophylaxis for ophthalmia neonatorum caused by Neisseria gonorrhoeae, preventing severe eye infections.