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
G4T1 P1 A1 L2 implies the client has been pregnant 4 times, with 1 term birth, 1 preterm birth, 1 abortion, and 2 living children. This does not include the correct number of
pregnancies or abortions for this client.
Choice B rationale
G5T2 P0 A2 L2 indicates 5 pregnancies, 2 term births, no preterm births, 2 abortions, and 2 living children. This does not correctly account for the preterm birth and abortion history
provided.
Choice C rationale
G5T1 P1 A2 L2 is the correct answer, as it denotes 5 pregnancies (including the current one), 1 term birth, 1 preterm birth, 2 abortions, and 2 living children, aligning with the client's
history.
Choice D rationale
G5T1 P1 A1 L3 indicates 5 pregnancies, 1 term birth, 1 preterm birth, 1 abortion, and 3 living children. The client has only 2 living children, so this is incorrect.
Correct Answer is B
Explanation
Choice A rationale
Accidental lacerations are possible during a cesarean delivery, but they are typically managed quickly and are not the most critical issue immediately after birth.
Choice B rationale
Respiratory distress is the priority assessment for a newborn following a cesarean delivery because cesarean births can increase the risk of transient tachypnea or other respiratory complications due to the lack of labor-induced respiratory adaptation.
Choice C rationale
Hypothermia is a concern for all newborns, but respiratory distress takes precedence in the immediate post-delivery period, especially following cesarean delivery.
Choice D rationale
Acrocyanosis is a common and typically benign condition in newborns, not requiring immediate intervention compared to respiratory distress.