A nurse is planning care for a client who is pregnant and has HIV. Which of the following actions should the nurse include in the plan of care?

Correct Answer: C

Rationale: Administering a pneumococcal immunization to the newborn within 4 hours following birth is a crucial action to include in the plan of care for a pregnant client with HIV. Infants born to HIV-positive mothers are at higher risk for infections, including pneumococcal disease. Administering a pneumococcal vaccine shortly after birth helps protect the newborn from this serious infection. It is important to follow established guidelines for immunizations in newborns of HIV-positive mothers to optimize the infant's health outcomes.

Correct Answer: C

Rationale: The client presses a button during fetal movements, which are correlated with fetal heart rate changes.

Correct Answer: D

Rationale: The correct action for the nurse to take in this situation is to reassess the blood glucose level prior to the next feeding. A single low bedside glucometer reading is not sufficient to make treatment decisions, especially in a newborn who is only 6 hours old and with a mother having type 2 diabetes mellitus. It is important to follow up with another blood glucose measurement before taking further action. This will help ensure that appropriate interventions are taken based on accurate and reliable information.

Correct Answer: C

Rationale: Placenta previa presents as painless bright red bleeding and a soft, non-tender uterus.

Correct Answer: C

Rationale: As the fetus descends into the pelvis (lightening), increased pressure on the bladder causes frequent urination.