The nurse is evaluating the goal Patient will remain free of ...

[scienceeasy]

The nurse is evaluating the goal Patient will remain free of opportunistic infections for an HIV-positive pregnant patient.
 
  The nurse determines the goal was met when the patient: Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Has an absolute CD4+ T-lymphocyte count below 200.
  2. Has no complaint of chills or fever during the pregnancy.
  3. Has a weight gain of 30 lbs. during the pregnancy.
  4. Has a white blood cell count of 2500 at 30 weeks' gestation.
  5. Maintains a normal erythrocyte sedimentation rate during the pregnancy.

Question 2

A woman has just delivered a stillborn child at 26 weeks' gestation. Which nursing action is appropriate at this time?
 
  1. Remind the mother that she will be able to have another baby in the future.
  2. Dress the infant in a gown and swaddle it in a receiving blanket.
  3. Ask the woman whether she would like the doctor to prescribe a sedative for her.
  4. Remove the baby from the delivery room as soon as possible.

[vseab]

Answer to Question 1

2,3,5
Rationale 1: The absolute CD4+ T-lymphocyte count must remain above 200 to protect against opportunistic infections.
Rationale 2: Not having chills, fever, or a sore throat throughout the pregnancy is an indication the patient did not have an infection.
Rationale 3: Twenty-five to thirty pounds in weight gain is normal for a pregnancy. This patient met the goal for nutrition and remaining infection-free.
Rationale 4: This is a low white blood cell count, and indicates the patient is at risk for developing an infection.
Rationale 5: Having a normal erythrocyte sedimentation rate during the pregnancy is an expected outcome.

Answer to Question 2

2
Rationale 1: This is not appropriate, as no baby can take the place of this one and the mother needs to be able to grieve for this baby.
Rationale 2: It is appropriate to put a little gown on the baby and wrap it in a blanket before giving it to the parents, who can unwrap and view the baby if they wish.
Rationale 3: The woman likely will ask for a sedative if she wants one.
Rationale 4: This not appropriate, as the parents have the right to spend time with their baby.

[scienceeasy]

Gracias!

[Alyson.hiatt@yahoo.com]

Excellent