Nokea
A nurse is planning care for a client who is pregnant and has HIV. Which of the following actions should the nurse include in the plan of care?
- A. Instruct the client to stop taking the antiretroviral medication at 32 weeks of gestation.
- B. Use a fetal scalp electrode during labor and delivery.
- C. Administer a pneumococcal immunization to the newborn within 4 hr. following birth.
- D. Bathe the newborn before initiating skin-to-skin contact
Correct Answer: C
Rationale: Administering a pneumococcal immunization to the newborn within 4 hours following birth is a crucial action to include in the plan of care for a pregnant client with HIV. Infants born to HIV-positive mothers are at higher risk for infections, including pneumococcal disease. Administering a pneumococcal vaccine shortly after birth helps protect the newborn from this serious infection. It is important to follow established guidelines for immunizations in newborns of HIV-positive mothers to optimize the infant's health outcomes.
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A client at 12 weeks' gestation reports mild cramping and spotting. What is the nurse's priority intervention?
- A. Reassure the client that this is normal.
- B. Encourage the client to hydrate.
- C. Advise the client to avoid heavy lifting.
- D. Notify the healthcare provider immediately.
Correct Answer: D
Rationale: Spotting and cramping in early pregnancy could indicate a threatened miscarriage, requiring immediate evaluation.
Which complication of adolescent pregnancy should the nurse plan to monitor?
- A. Anemia
- B. Placenta previa
- C. Abruptio placenta
- D. Incompetent cervix
Correct Answer: D
Rationale: Incompetent cervix, also known as cervical insufficiency, is a condition where the cervix begins to dilate and efface prematurely due to weak cervical tissue. This can lead to late miscarriage or preterm birth. Adolescent mothers are at a higher risk for this complication due to their immature reproductive systems. Therefore, the nurse should plan to monitor for signs and symptoms of incompetent cervix in adolescent pregnant clients to prevent adverse maternal and fetal outcomes. Anemia, placenta previa, and abruptio placenta are other potential complications of pregnancy, but they are not specifically associated with adolescent pregnancy.
The newborn's mother is concerned about the shape of the baby's head after delivery. She states that the baby looks like a "cone head." What is the most appropriate response by the nurse?
- A. "You don't need to worry about it. It is perfectly normal after birth."
- B. "It is molding caused by the pressure during birth and will disappear in a few days."
- C. "I will report it to the physician and recommend a diagnostic scan."
- D. "It is a collection of blood related to the trauma of delivery and will absorb in a few weeks.
Correct Answer: B
Rationale: "It is molding caused by the pressure during birth and will disappear in a few days."
The nurse is caring for a postpartum client who is
- A. Maternal hyperglycemia 1 day postcesarean birth. What assessment data
- B. FHR, early decelerations would indicate infection? Select all that apply.
- C. FHR, late decelerations
- D. Increased pulse
Correct Answer: A
Rationale: Maternal hyperglycemia 1 day post-cesarean birth can indicate infection. Hyperglycemia can impair immune function and make the body more susceptible to infections.
Which lifestyle factor is associated with an increased risk of developing breast cancer?
- A. regular physical activity
- B. moderate alcohol consumption
- C. maintaining a healthy weight after menopause
- D. excessive alcohol consumption
Correct Answer: D
Rationale: