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A nurse is admitting a client in labor who is HIV positive.
Which intervention is contraindicated for this client?

A.

Application of external fetal monitors.

B.

Prepare to administer antiviral medication.

C.

Preparation for caesarean section delivery.

D.

Application of internal fetal scalp electrode.

Answer and Explanation

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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View Related questions

Correct Answer is A

Explanation

Choice A rationale

A boggy and displaced fundus typically indicates bladder distention. Assisting the client to void can help relieve bladder distention, allowing the uterus to contract properly and

reducing the risk of postpartum hemorrhage.

Choice B rationale

Asking the client to rate her pain is important, but it does not address the immediate issue of a boggy, displaced fundus, which suggests bladder distention.

Choice C rationale

Encouraging the client to move to the left lateral position might help with blood flow and comfort but does not resolve the issue of a boggy fundus due to bladder distention.

Choice D rationale

Kegel exercises strengthen pelvic floor muscles but do not address the immediate concern of a boggy, displaced fundus caused by bladder distention.

Correct Answer is A

Explanation

Choice A rationale

Administering antipyretics for maternal fever is essential as elevated maternal temperatures can increase the risk of fetal tachycardia and potentially lead to fetal distress. Reducing

fever promptly is a priority to stabilize both maternal and fetal conditions.

Choice B rationale

Preparing for an emergency cesarean section is not the immediate step for maternal fever; instead, managing the fever and assessing the need for further interventions based on the

overall clinical picture should be prioritized.

Choice C rationale

Administering glucocorticoids is indicated for promoting fetal lung maturity in preterm labor, not specifically for maternal fever management. Fever management requires antipyretics

and hydration.

Choice D rationale

Waiting 4 hours to recheck temperature delays prompt management, increasing risks for both the mother and fetus. Immediate action to reduce fever is crucial to prevent potential

complications.

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