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
Accelerations are increases in the fetal heart rate (FHR) above the baseline, typically in response to fetal movement or uterine contractions. They indicate a healthy, well-oxygenated
fetus and are not consistent with the described pattern of decelerations.
Choice B rationale
Late decelerations are characterized by a gradual decrease in FHR that begins after the contraction has started, with the lowest point of the deceleration (nadir) occurring after the
peak of the contraction. They are associated with uteroplacental insufficiency and fetal hypoxia, which is not described in the scenario.
Choice C rationale
Early decelerations are a gradual decrease in FHR that mirrors the contraction, starting with the contraction and returning to baseline as the contraction ends. The nadir of the
deceleration occurs at the peak of the contraction, which fits the pattern described.
Choice D rationale
Variable decelerations are abrupt decreases in FHR that can occur at any time during the contraction cycle, usually due to umbilical cord compression. They are not uniform in
relation to contractions and can vary in duration, depth, and timing, unlike the described pattern.
Correct Answer is D
Explanation
Choice A rationale
Elevated WBC count is not typically associated with HELLP syndrome. HELLP syndrome involves hemolysis, elevated liver enzymes, and low platelet count.
Choice B rationale
Elevated platelet count is not a feature of HELLP syndrome. In fact, thrombocytopenia (low platelet count) is a hallmark of the condition.
Choice C rationale
Decreased BUN is not a characteristic of HELLP syndrome. The syndrome primarily affects liver function and platelets.
Choice D rationale
Elevated liver enzymes are a key diagnostic feature of HELLP syndrome, reflecting liver dysfunction and damage, which is part of the condition's pathology. .