Page 837 - Saunders Comprehensive Review For NCLEX-RN

5. Assess suck and swallow reflex.
6. Administer small feedings and burp well.
7. Suction as necessary.
8. Monitor intake and output.
9. Monitor weight and head circumference.
10. Decrease environmental stimuli.
11. Make referral to local early intervention system.
XXIV. Newborn of a Mother With Human Immunodeficiency Virus (HIV)
A. Description
1. The fetus of a mother who is positive for HIV antibody
should be monitored closely throughout the
pregnancy.
2. Serial ultrasound screenings should be done during
pregnancy to identify IUGR.
3. Weekly nonstress testing after 32 weeks of gestation
and biophysical profiles may be necessary during
pregnancy.
4. Newborns born to HIV-positive mothers may test
positive because the mother’s antibodies may persist
in the newborn for 18 months after birth.
5. The use of antiviral medication, the reduction of
newborn exposure to maternal blood and body fluids,
and the early identification of HIV in pregnancy
reduce the risk of transmission to the newborn.
6. All newborns born to HIV-positive mothers acquire
maternal antibody to HIV infection, but not all
acquire the infection.
7. The newborn may be asymptomatic for the first
several months to years of life.

B. Transmission

1. Across placental barrier
2. During labor and birth
3. Breast milk (breast-feeding not done if the mother is
HIV-positive; follow PHCP prescription)
C. Assessment
1. Possibly no outward signs at birth
2. Signs of immunodeficiency
3. Hepatomegaly
4. Splenomegaly
5. Lymphadenopathy
6. Impairment in growth and development

D. Interventions

1. Clean the newborn’s skin carefully before any invasive
procedure, such as the administration of
phytonadione, heel sticks, or venipunctures.

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