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
Clapping hands to assess hearing is not a reliable method and could startle the baby for reasons unrelated to hearing ability.
Choice B rationale
While a newborn might respond to visual stimuli, this is not a definitive method to assess hearing.
Choice C rationale
Routine hearing screenings using objective tests are the best way to determine a newborn's hearing ability, providing accurate and early detection of potential hearing issues.
Choice D rationale
This statement is misleading, as some forms of hearing loss can be inherited. It's important to use accurate methods to assess newborn hearing.
Correct Answer is A
Explanation
Choice A rationale
A respiratory rate of 10/min is concerning as it indicates possible respiratory depression, which can be a side effect of spinal anesthesia. This requires immediate intervention to
prevent hypoxia and other complications.
Choice B rationale
Blood pressure of 100/70 mm Hg is within normal limits and does not require immediate intervention in this context.
Choice C rationale
Urinary output of 30 ml/hr is slightly low, but it is not immediately life-threatening. It may require monitoring and further assessment if it persists.
Choice D rationale
A headache pain rated a 6 on a scale of 0 to 10 could indicate a post-dural puncture headache, which is common after spinal anesthesia. It requires attention but is not an immediate
life-threatening condition. .