A nurse is preparing a sterile field for a client who requires a sterile procedure. Which of the following actions should the nurse plan to take?
Open the sterile drape by touching the inner surface first.
Place sterile items within a 1-inch border of the drape.
Hold sterile instruments above the waist and away from the body.
Pour sterile solution directly from a container held 12 inches above.
The Correct Answer is C
Choice A reason: Touching the inner surface of a sterile drape first contaminates it, as only sterile gloves should contact this area. Outer edges are handled to maintain sterility, so this action violates sterile technique, making it incorrect.
Choice B reason: Placing items within a 1-inch border of the drape is incorrect, as this border is considered non-sterile. Sterile items must be placed centrally to avoid contamination, so this action breaches sterile field principles, making it incorrect.
Choice C reason: Holding sterile instruments above the waist and away from the body maintains sterility, as areas below the waist or close to the body are considered contaminated. This aligns with aseptic technique, making it the correct action for sterile field preparation.
Choice D reason: Pouring solution from 12 inches above risks splashing, contaminating the sterile field. Solutions should be poured from 4-6 inches to control flow and maintain sterility, so this action is incorrect and unsafe for sterile procedures.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Supplementing breastfeedings with water every 12 hours is not advised for newborns, as breast milk provides complete hydration and nutrition. Water can reduce milk intake, decreasing supply due to reduced demand. It risks electrolyte imbalances, like hyponatremia, in infants with immature kidneys. Exclusive breastfeeding for six months supports optimal growth, immune function, and maternal-infant bonding, making this recommendation inappropriate.
Choice B reason: Offering the breast at hunger cues, such as rooting or hand-sucking, supports demand-driven breastfeeding, which stimulates prolactin and oxytocin for milk production. This ensures adequate supply, promotes healthy weight gain, and aligns with the infant’s natural feeding rhythm. It prevents over- or under-feeding, fostering neonatal development and strengthening the maternal-infant bond, making this the correct advice.
Choice C reason: Limiting feeding to 10 minutes per breast can prevent adequate hindmilk transfer, which is high in fat and calories, essential for growth. Short sessions may reduce milk supply due to insufficient stimulation. Infants need variable feeding times to meet nutritional needs. This restriction risks poor weight gain and inadequate nutrition, indicating it’s not a suitable recommendation.
Choice D reason: Starting each feeding with the same breast can cause imbalanced milk production, as one breast may be understimulated, reducing overall supply. Alternating breasts ensures both are drained, supporting balanced lactation and preventing engorgement or mastitis. This practice maintains milk supply via prolactin release, making this advice incorrect for optimal breastfeeding.
Correct Answer is D
Explanation
Choice A reason: Assuring the client about future pregnancies dismisses her current emotional loss, potentially invalidating grief. Stillbirth triggers complex hormonal and psychological responses, including postpartum depression risk. This approach fails to address immediate emotional needs, hindering the grieving process and emotional recovery in perinatal loss.
Choice B reason: Avoiding discussion of the newborn ignores the client’s need to process her loss. Acknowledging the baby’s existence is critical for healthy mourning, as psychological research shows verbalizing grief aids emotional integration. Silence may suppress coping, prolonging unresolved grief and complicating psychological adjustment post-stillbirth.
Choice C reason: Discouraging friends from seeing the newborn dismisses the client’s need for social support. Communal acknowledgment of loss mitigates isolation, a key factor in grief recovery. This action disrupts psychological coping by limiting social validation, potentially exacerbating feelings of loneliness and hindering emotional healing after stillbirth.
Choice D reason: Offering to take pictures acknowledges the baby’s significance, aiding the client’s grieving process. Photographs serve as tangible memories, supported by psychological research as therapeutic in perinatal loss. This intervention fosters emotional closure, validates the loss, and supports healthy mourning, aligning with compassionate care principles.
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