1047) The nurse encourages a pregnant human immunodeficiency virus (HIV)–positive client to report any early signs of vaginal discharge or perineal tenderness to the health care provider immediately. The client asks the nurse about the importance of this action, and the nurse responds by telling the client which accurate statement?
1. "This is necessary to relieve anxiety for the pregnant client."
2. "This is necessary to eliminate the need for further uncomfortable screenings."
3. "This is necessary to minimize the financial cost of caring for an HIV-positive client."
4. "This is necessary to assist in identifying potential infections that may need to be treated."
Answer: 4. The HIV-compromised client may be at high risk for superimposed infections during pregnancy. These include Candida infections, genital herpes, and anogenital condyloma. Early reporting of symptoms may alert the members of the health care team that further assessment and testing are needed to diagnose and manage additional maternal and fetal physiological risks. All other options do represent possible outcomes of this nursing intervention, but they are not the priority of care when promoting maternal-fetal well-being.
1048) The nurse is preparing to administer an injection of vitamin K to a newborn. Which injection site should the nurse select?
1. The gluteal muscle
2. The lower aspect of the rectus femoris muscle
3. The medial aspect of the upper third of the vastus lateralis muscle
4. The lateral aspect of the middle third of the vastus lateralis muscle
Answer: 4. The preferred injection site for vitamin K in the newborn infant is the lateral aspect of the middle third of the vastus lateralis muscle in the infant's thigh. This muscle is the preferred injection site because it is free of major blood vessels and nerves and is large enough to absorb the medication.
1049) The nurse is providing instructions to a pregnant client with human immunodeficiency virus (HIV) infection regarding care to the newborn after delivery. The client asks the nurse about the feeding options that are available. Which response should the nurse make to the client?
1. "You will need to bottle-feed your newborn."
2. "You will need to feed your newborn by nasogastric tube feeding."
3."You will be able to breast-feed for 6 months and then will need to switch to bottle-feeding."
4. "You will be able to breast-feed for 9 months and then will need to switch to bottle-feeding."
Answer:1. Perinatal transmission of human immunodeficiency virus (HIV) can occur during the antepartum period, during labor and birth, or in the postpartum period if the mother is breast-feeding. Clients who have HIV are advised not to breast-feed. There is no physiological reason why the newborn needs to be fed by nasogastric tube.