HIV/AIDS Nursing Insights

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Questions and Answers

What is the primary purpose of an amniotomy during labor?

To prevent cord prolapse

To increase the amount of amniotic fluid

To artificially rupture the amniotic membranes (correct)

To induce contractions with medication

Which of the following is NOT a complication associated with an amniotomy?

Nonreasoning fetal heart rate

Increased uterine pressure (correct)

Infection

Cord prolapse

When should a nurse monitor the fetal heart rate (FHR) in relation to an amniotomy?

Only after artificial rupture of membranes

Only if the amniotic fluid is meconium-stained

Before administering misoprostol

Continuously during labor (correct)

What nursing intervention is crucial to perform before conducting an amniotomy?

Ensure the presenting part of the fetus is engaged Signup and view all the answers

What is the primary indication for performing an amnioinfusion?

To supplement the amount of amniotic fluid Signup and view all the answers

What are common expected findings associated with internal bleeding during pregnancy?

Ripping or tearing pain Signup and view all the answers

Which nursing intervention is vital for managing Anaphylactoid Syndrome of Pregnancy?

Intubate or provide mechanical ventilation Signup and view all the answers

Which risk factors are associated with Anaphylactoid Syndrome of Pregnancy?

Use of oxytocin and meconium-stained fluid Signup and view all the answers

What signs might indicate hypovolemic shock resulting from internal bleeding?

Nonreassuring FHR and uterine tenderness Signup and view all the answers

In cases of internal bleeding, which symptom is least likely to be observed?

Shortness of breath Signup and view all the answers

What is the primary goal of nursing actions for a client with HIV?

Maintain CD4 cell count above 500 Signup and view all the answers

Which of the following symptoms are typically associated with the early onset of labor?

Uterine contractions and cervical changes Signup and view all the answers

What is a common risk factor for developing preeclampsia?

Advanced maternal age Signup and view all the answers

Which medication is NOT typically used for managing early onset of labor?

Ibuprofen Signup and view all the answers

What does PROM stand for in the context of pregnancy?

Premature rupture of membranes Signup and view all the answers

What would indicate the need for a cesarean delivery in a client with a high maternal viral load?

Viral load greater than 1,000 copies Signup and view all the answers

What is an expected finding in a client experiencing preterm labor?

Low back pain and vaginal discharge Signup and view all the answers

Which condition is characterized by severe preeclampsia with the occurrence of seizures?

Eclampsia Signup and view all the answers

In the context of HIV management during pregnancy, what is the recommended timing for administering HAART?

3 hours before delivery and for 6 weeks post-birth Signup and view all the answers

What is a common expected finding in a patient with meconium-stained amniotic fluid?

Black to green or yellow amniotic fluid Signup and view all the answers

Which nursing intervention is critical when meconium is present in the amniotic fluid?

Suction below the vocal cords using an endotracheal tube if HR is 40 Signup and view all the answers

What defines precipitous labor?

Labor that lasts 3 hours or less from the onset of contractions to delivery Signup and view all the answers

Which of the following are indications for a vacuum-assisted delivery?

Cervical dilation of 10 cm Signup and view all the answers

Which complication may occur in the fetus due to precipitous labor?

Hypoxia Signup and view all the answers

What nursing intervention is essential when preparing for artificial rupture of membranes?

Warm fluid via blood warmer Signup and view all the answers

What is a possible risk factor for the development of uterine rupture?

Use of oxytocin during labor Signup and view all the answers

What is a major difference between complete and incomplete uterine rupture?

Incomplete rupture involves dehiscence at a prior scar site Signup and view all the answers

Which complication is associated with the use of forceps during delivery?

Cervical lacerations Signup and view all the answers

Which nursing intervention should be prioritized during precipitous labor?

Encourage panting with an open mouth between contractions Signup and view all the answers

What is a primary indication for performing an episiotomy?

To facilitate vacuum-assisted delivery Signup and view all the answers

Which of the following statements about vacuum-assisted delivery is incorrect?

It cannot be used in the case of a ruptured membrane. Signup and view all the answers

Which of the following should be documented while caring for a client with meconium-stained amniotic fluid?

Color and consistency of amniotic fluid Signup and view all the answers

What is a potential complication of cesarean birth?

Injury to the bladder Signup and view all the answers

Which of the following is not required when using forceps during delivery?

Urinary tract infection history Signup and view all the answers

What is the primary purpose of performing an amniotomy?

To facilitate monitoring fetal health Signup and view all the answers

Study Notes

HIV/AIDS

Retrovirus that attacks and destroys T lymphocytes
Causes immunosuppression in client
Transmission: Perinatal (through placenta) and postnatal (through breast milk)
Risk factors: IV drug use, multiple sexual patterns, history of STIs
Expected findings:
- Fatigue
- Influenza-like symptoms
- Fever
- Diarrhea
- Weight loss
- Lymphadenopathy
- Rash
- Anemia
Labs:
- Enzyme immunoassay (EIA) confirmed by Western blood or immunofluorescence assay
- Viral load levels
- CD4 cell counts
Nursing actions:
- Goal: Keep CD4 cells > 500
- Use standard precautions
- Administer antiretroviral prophylaxis:
  - Triple-medication antiretroviral (ART) throughout pregnancy
  - Highly active antiretroviral therapy (HAART) 3 hours prior to delivery and 6 weeks following birth to infant
- Immunization: Hep B, pneumococcal infection, Haemophilus influenzae type b, and viral influenza
- Use condoms
- Cesarean section: Maternal viral load > 1,000 copies or vaginal delivery can be done for viral load 160/110 with:
  - Proteinuria +3
  - Oliguria
  - Creatinine > 1.1
  - Headache
  - Blurred vision
  - Hyperreflexia
  - Edema
  - Hepatic dysfunction
  - Epigastric and RUQ pain

Preeclampsia & Eclampsia

Eclampsia: Severe preeclampsia with seizure or coma
HELLP syndrome: Hemolysis, elevated liver enzymes, low platelets
Risk factors:
- Age 40 or older
- First pregnancy
- Obesity
- Multifetal gestation
- Renal disease
- Hypertension
- Family history
Medications:
- Low-dose aspirin in late first trimester for history of preeclampsia
- Antihypertensives: Methyldopa, nifedipine, hydralazine, or labetalol
- Magnesium sulfate

Preterm Labor

Uterine contractions and cervical changes between 20 and 36 weeks and 6 days of gestation
Risk factors:
- Infections
- History of preterm labor
- Multifetal pregnancy
- Smoking
- Substance abuse
- Violence
Expected findings:
- Uterine contractions
- Cramping
- Low back pain
- Urinary frequency
- Vaginal discharge
- Cervical dilation
Labs:
- Fetal fibronectin
- Cervical cultures
- CBC
- Urinalysis
Nursing interventions:
- Activity restriction
- Hydration
- Treating infection
- Monitor fetal heart rate and contraction pattern
- Fetal tachycardia
Medications:
- Nifedipine
- Magnesium sulfate
- Terbutaline
- Betamethasone

Premature Rupture of Membranes (PROM)

Spontaneous rupture of membranes prior to true labor
Premature PROM: Rupture of membranes between 20 and 37 weeks
Risk factors:
- Infections
- History of PROM
- Shortened cervix
- Tobacco/substance abuse
Expected findings:
- Gush or leakage of fluids from vagina
Labs:
- Positive nitrazine paper test
Nursing interventions:
- Monitor fetal heart rate
- Assess for prolapsed cord
- Vaginal examinations
- Limit vaginal exams
- Vital signs
- CBC
- Antibiotics
Medications:
- Ampicillin
- Betamethasone
Education:
- Limit activity
- Daily kick counts
- Report foul-smelling vaginal discharge
- Avoid intercourse
- Take temperature
Complications:
- Infection
- Placental abruption
- Umbilical cord compression/prolapse
- Fetal pulmonary hypoplasia
- Fetal death

External Cephalic Version

Ultrasound-guided hands-on procedure to externally manipulate the fetus into a cephalic lie at 37-38 weeks
Contraindications:
- Uterine anomalies
- Previous Cesarean birth
- Cephalopelvic disproportion
- Placenta previa
- Multifetal gestation
- Oligohydramnios
- Third-trimester bleeding
- Uteroplacental insufficiency
- Nuchal cord
Indications:
- Gestational age > 42 weeks
- Dystocia
- Prolonged rupture of membranes
- Intrauterine growth restriction
- Maternal medical complications: Diabetes, pulmonary disease, gestational hypertension
- Fetal demise
- Chorioamnionitis
Nursing interventions:
- Misoprostol administration
- Oxytocin administration
- Ensure infusion port is closest to the client and connected to the main IV line
- Monitor contractions
- Vital signs
- Fetal heart rate
Complications:
- Non-reassuring fetal heart rate

Amniotomy

Artificial rupture of the amniotic membranes (AROM) by provider using hook, clamp, or other sharp instrument
Labor typically begins within 12 hours after membranes rupture
Can decrease the duration of labor by up to 2 hours
Indication: Labor progression too slow; induction of labor is indicated
Nursing interventions:
- Ensure presenting part of the fetus is engaged prior to prevent cord prolapse
- Monitor fetal heart rate
- Assess characteristics of amniotic fluid
- Document time of rupture
Complications:
- Cord prolapse
- Infection

Amnioinfusion

Instillation of normal saline or lactated Ringer's into the amniotic cavity through a transcervical catheter introduced into the uterus to supplement the amount of amniotic fluid
Indications:
- Oligohydramnios
- Fetal cord compression
Nursing interventions:
- Assist with amniotomy if membranes haven't ruptured
- Warm fluid via blood warmer
- Monitor uterine distention
- Monitor uterine contractions
- Monitor fetal heart rate
- Monitor fluid output

Vacuum Assisted Delivery

Use of a cup-like suction device that is attached to the fetal head
Indications:
- Vertex presentation
- Cervical dilation of 10 cm
- Cephalopelvic disproportion
- Ruptured membranes
- Fetal distress
Nursing interventions:
- Monitor fetal heart rate
- Observe for neonatal bruising, abrasions, and facial palsy
- Check client for lacerations and hematoma
- Report to postpartum nurse that vacuum-assisted delivery was used
Complications:
- Lacerations of cervix, vagina, and perineum
- Injury to bladder
- Facial nerve palsy of neonate
- Facial bruising
- Subdural hematoma

Forceps

Instrument with two curved spoon-like blades to assist in the delivery of the fetal head
Traction applied during contractions
Indications:
- Prolonged second stage of labor
- Fetal distress
- Abnormal presentation
Interventions:
- Lithotomy position
- Empty bladder
- Ensure fetus is engaged
- Assess fetal heart rate
- Observe for bruising and abrasions
- Observe for vaginal/cervical lacerations
Complications:
- Lacerations of cervix, vagina, and perineum
- Injury to bladder
- Facial nerve palsy of neonate
- Facial bruising
- Subdural hematoma

Episiotomy

Incision made into the perineum to enlarge the vaginal opening to facilitate birth and minimize soft-tissue damage
Indications:
- Shorten the second stage of labor
- Facilitate forceps or vacuum-assisted delivery
- Prevent cerebral hemorrhage in preterm fetus
- Facilitate birth of macrosomia infant

Cesarean Birth

Delivery of the fetus through a transabdominal incision of the uterus to preserve the life or health of the client and fetus when there is evidence of complications

Meconium-Stained Amniotic Fluid

Meconium passage in the amniotic fluid
Risk factors:
- Gestational age > 38 weeks
- Umbilical cord compression
- Hypoxia stimulates vagal nerve
Expected findings: Black to green or yellow amniotic fluid
Nursing interventions:
- Document amniotic fluid
- Notify the provider
- Gather resuscitation equipment
- Suction mouth and nose
- Suction below the vocal cords using an endotracheal tube if heart rate < 100
Complications:
- Fetal aspiration
- Fetal distress
- Respiratory distress

Dystocia

Difficult labor due to problems with the powers of labor, the passenger, the passageway, or a combination of factors
Causes:
- Uterine dysfunction (hypotonic or hypertonic)
- Fetal malposition or malpresentation
- Cephalopelvic disproportion
- Uterine abnormalities
- Fetal macrosomia
- Multifetal pregnancy
Expected findings:
- Lack of progress in dilation, effacement, or fetal descent during labor
- Ineffective pushing
- Occiput posterior position
Diagnostics:
- Ultrasound
- Amniotomy
- Oxytocin
- Vacuum-assisted birth
- Cesarean section
Nursing interventions:
- Assist with fetal scalp electrode
- Encourage client to void
- Position changes
- Ambulation
- Hydrotherapy
- Counterpressure
Medications:
- Oxytocin

Precipitous Labor

Labor that lasts 3 hours or less from the onset of contractions to the time of delivery
Risk factors:
- Hypertonic uterine dysfunction
- Oxytocin stimulation
- Multiparous client
Expected findings:
- Low back pain
- Abnormal pressure/cramping
- Increased or bloody vaginal discharge
- Palpable uterine contractions
- Cervical dilation and effacement progressing rapidly
- Diarrhea
- Fetal presentation, station, and position
Nursing interventions:
- Do not leave client unattended
- Encourage panting with an open mouth between contractions
- Side-lying position
- Do not stop delivery
- Apply light pressure to the perineal area and fetal head
Complications:
- Maternal:
  - Lacerations
  - Tissue trauma
  - Uterine rupture
  - Amniotic fluid embolism
  - Hemorrhage
- Fetal:
  - Hypoxia
  - Intracranial hemorrhage

Uterine Rupture

Complete rupture: Involves the uterine wall, peritoneal cavity, and/or broad ligament; internal bleeding present
Incomplete rupture: Dehiscence at the site of a prior scar (Cesarean birth, surgical intervention); internal bleeding might not be present
Risk factors:
- Uterine abnormality
- Uterine trauma
- Overdistention of uterus
- Hyperstimulation of uterus
- External/internal version
- Forceps
Expected findings:
- Ripping or tearing or sharp pain
- Uterine tenderness
- Non-reassuring fetal heart rate (bradycardia, variable and late decelerations)
- Change in uterine shape
- Hypovolemic shock
Nursing interventions:
- IV fluids
- Oxygen
- Administer blood products
- Immediate Cesarean section

Anaphylactoid Syndrome of Pregnancy (Amniotic Fluid Embolism)

Occurs when there is a rupture in the amniotic sac or maternal uterine veins that causes infiltration of the amniotic fluid into the maternal circulation
Amniotic fluid travels to and obstructs pulmonary vessels and causes respiratory distress and circulatory collapse
Risk factors:
- Placenta previa or abruption
- Preeclampsia
- Eclampsia
- Oxytocin
- Diabetes
- Cesarean section
- Forceps
- Uterine rupture
- Meconium-stained fluid
Expected findings:
- Sudden chest pain
- Shortness of breath
- Restlessness
- Cyanosis
- Dyspnea
- Bleeding from incisions
- Petechiae
- Ecchymosis
- Increased heart rate
- Decreased blood pressure
Nursing interventions:
- Oxygen
- Intubation/mechanical ventilation
- CPR
- IV fluids
- Side-lying with pelvis tilt
- Blood products
- Catheter to monitor intake and output
- Emergency Cesarean section

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Description

This quiz covers essential nursing information about HIV/AIDS, including its transmission methods, risk factors, expected findings, and laboratory assessments. Participants will also learn about effective nursing actions to manage patients living with HIV/AIDS, emphasizing the importance of maintaining CD4 cell counts and administering antiretroviral therapy.