A nurse is preparing to administer purified protein derivative (PPD) to a client. The nurse should use which of the following routes?

Subcutaneous

Intramuscular

Intradermal

Oral

Answer and Explanation

The Correct Answer is C

A. Subcutaneous: The subcutaneous route deposits medication into the fatty tissue beneath the skin. PPD testing requires a slow, localized immune reaction, which cannot be accurately assessed if administered subcutaneously, making this route inappropriate.

B. Intramuscular: Intramuscular injections deliver medication into muscle tissue for systemic absorption. PPD relies on a localized delayed-type hypersensitivity reaction in the dermis, so IM administration would prevent accurate interpretation of the test.

C. Intradermal: PPD is administered intradermally, usually on the inner forearm, to produce a small, raised wheal. This allows for proper exposure of immune cells in the dermis to the antigen, enabling assessment of induration 48–72 hours later and accurate detection of tuberculosis exposure.

D. Oral: Oral administration does not provide a localized skin reaction necessary for PPD testing. The immune response required for interpreting the test cannot occur via the gastrointestinal route, making oral administration inappropriate.

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Correct Answer is C

Explanation

A. Infant bassinets should be positioned 24 in (2 feet) apart: To reduce the risk of cross-contamination and droplet transmission, infant bassinets should be spaced at least 3 feet (approximately 91 cm) apart. Positioning them only 2 feet apart does not provide adequate protection against respiratory droplet spread.

B. Staff should avoid using alcohol-based hand rubs to perform hand hygiene: Alcohol-based hand rubs are recommended and effective for routine hand hygiene when hands are not visibly soiled. They reduce bacterial load quickly, are convenient, and are endorsed by the CDC as part of standard infection control practices in maternal-newborn units.

C. Visitors who have an upper respiratory infection should wear a mask: Wearing a mask helps prevent transmission of respiratory pathogens to newborns, who are highly susceptible to infections. Requiring symptomatic visitors to use masks is an essential infection control measure to protect vulnerable infants in the unit.

D. Pumped breastmilk can be left at room temperature for 6 hr: According to CDC and AAP guidelines, freshly expressed breast milk can be safely stored at room temperature (up to 77°F or 25°C) for no more than 4 hours. Leaving it for 6 hours increases the risk of bacterial growth and infection.

A. "I will make sure that my baby has at least six wet diapers a day." B. "I can reuse any breast milk my baby does not drink for the next feeding." C. "I will feed my baby each time he cries." D. "I can give my baby water following each feeding.”

Correct Answer is A

Explanation

A. "I will make sure that my baby has at least six wet diapers a day.": After the first week of life, at least six wet diapers per day indicates adequate hydration and sufficient breast milk intake. Urine output is a reliable indicator of effective breastfeeding and appropriate milk transfer. Monitoring diaper count helps assess nutritional adequacy.

B. "I can reuse any breast milk my baby does not drink for the next feeding.": Once a baby has fed from a bottle, bacteria from the infant’s mouth can contaminate the remaining milk. Reusing leftover milk increases the risk of bacterial growth and infection. Expressed breast milk that has been partially consumed should be discarded.

C. "I will feed my baby each time he cries.": Crying is a late sign of hunger. Early hunger cues include rooting, sucking motions, and hand-to-mouth movements. Waiting until the infant cries may make latching more difficult and interfere with effective feeding.

D. "I can give my baby water following each feeding.": Exclusively breastfed infants do not require supplemental water. Breast milk provides adequate hydration, even in warm climates. Giving water can interfere with feeding patterns and may lead to inadequate caloric intake or electrolyte imbalance.

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A nurse is preparing to administer purified protein derivative (PPD) to a client. The nurse should use which of the following routes?

Nursing Test Bank

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