A nurse is admitting a client in labor who is HIV positive.
Which intervention is contraindicated for this client?
Application of external fetal monitors.
Prepare to administer antiviral medication.
Preparation for caesarean section delivery.
Application of internal fetal scalp electrode.
The Correct Answer is D
Choice A rationale
External fetal monitors are non-invasive and do not pose a risk of transmitting HIV from mother to baby. They are considered safe for monitoring fetal well-being in an HIV-positive mother.
Choice B rationale
Administering antiviral medication is essential in reducing the risk of mother-to-child transmission of HIV. It's a standard care practice for managing HIV-positive pregnant women.
Choice C rationale
Preparing for a caesarean section may be recommended to reduce the risk of vertical transmission of HIV during delivery, especially if the viral load is high.
Choice D rationale
Internal fetal scalp electrodes are contraindicated because they can create a portal for HIV transmission from mother to baby through small abrasions or punctures on the fetal scalp.
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Correct Answer is C
Explanation
Choice A rationale
A 10% to 15% increase in blood volume during pregnancy is too low compared to the average physiological changes that occur.
Choice B rationale
A 20% to 30% increase in blood volume is also below the expected range of increase during pregnancy.
Choice C rationale
Blood volume typically increases by 40% to 50% during pregnancy. This significant increase supports the demands of the growing fetus and placenta and prepares the mother's body for the blood loss that occurs during delivery.
Choice D rationale
A 65% to 75% increase is an overestimate. Such an extensive increase would be abnormal and is not typical in healthy pregnancies.
Correct Answer is D
Explanation
Choice A rationale
Administering the rubella vaccine during pregnancy, including the third trimester, is contraindicated due to the risk of live vaccine transmission to the fetus. It is not recommended at any stage of pregnancy.
Choice B rationale
Advising the client to get the vaccine during her next pregnancy attempt is partly correct but lacks the immediacy needed to ensure she is immune before the next pregnancy. The vaccine should be given postpartum.
Choice C rationale
Administering the vaccine immediately during pregnancy is contraindicated due to potential risks to the fetus. Rubella vaccines contain live virus, which can cause fetal harm if given during pregnancy.
Choice D rationale
It is safest to administer the rubella vaccine postpartum, prior to hospital discharge, to ensure the client has immunity before any future pregnancies. This timing prevents any risk to the current fetus and ensures future fetal protection. .