A nurse develops a plan of care for a human immunodeficiency virus (HIV)-infected mother and her newborn infant. The nurse includes which intervention in the plan of care?
  1. Instruct the breastfeeding mother regarding the treatment of the nipples with nystatin ointment
  2. Monitor the newborn infant’s vital signs routinely
  3. Maintain standard (universal) precautions at all times while caring for the newborn
  4. Initiate referral to evaluate for blindness, deafness, learning, or behavioral problems
Explanation
Answer: C - The newborn infant born of an HIV-infected mother must be cared for with strict attention to standard (universal) precautions. This prevents the transmission of HIV from the newborn infant, if infected, to others, and prevents transmission of other infectious agents to the possibly immunocompromised newborn infant, HIV infected mothers should not breastfeed.
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