A nurse is preparing to perform a sterile dressing change. Which of the following actions should the nurse take when setting up the sterile field?

Place the sterile dressing within 1.25 cm (0.5 in) of the edge of the sterile field.

Open the outermost flap of the sterile kit toward the body.

Place the cap from the solution sterile side up on a clean surface.

Set up the sterile field 5 cm (2 in) below waist level.

Answer and Explanation

The Correct Answer is C

A. Place the sterile dressing within 1.25 cm (0.5 in) of the edge of the sterile field: This action is not appropriate, as sterile items should be placed at least 2.5 cm (1 in) away from the edge of the sterile field to maintain sterility and prevent contamination.

B. Open the outermost flap of the sterile kit toward the body: The correct practice is to open the outermost flap away from the body. This technique helps prevent any contaminants from the nurse's clothing or body from falling into the sterile field.

C. Place the cap from the solution sterile side up on a clean surface: This is the correct action. By placing the cap sterile side up, the nurse minimizes the risk of contamination to the sterile solution and maintains the integrity of the sterile field.

D. Set up the sterile field 5 cm (2 in) below waist level: Setting up a sterile field below waist level increases the risk of contamination, as it may come into contact with non-sterile surfaces. The sterile field should be set up at waist level or higher to maintain sterility.

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Correct Answer is C

Explanation

A) Swaddle the newborn with his legs extended: This is not the appropriate way to swaddle a newborn. Swaddling should typically include flexing the legs to promote comfort and security, rather than extending them, which may be uncomfortable and less calming.

B) Maintain eye contact with the newborn during feedings: While establishing a bond with the newborn is important, excessive eye contact can overstimulate a newborn experiencing neonatal abstinence syndrome. The focus should be on creating a calming environment.

C) Minimize noise in the newborn's environment: This action is critical for a newborn experiencing neonatal abstinence syndrome, as these infants can be sensitive to stimuli. Reducing noise helps create a more soothing environment, which can alleviate symptoms of withdrawal.

D) Administer naloxone to the newborn: Naloxone is used to reverse opioid overdose, but it is not appropriate for routine treatment of neonatal abstinence syndrome. Management typically includes supportive care and, in some cases, pharmacologic treatment specific to the infant’s symptoms, rather than naloxone.

A. Ask a nursing student who speaks the same language as the client to translate. B. Allow the client's partner to translate. C. Request a female interpreter through the facility. D. Have the client's child translate.

Correct Answer is C

Explanation

A. Ask a nursing student who speaks the same language as the client to translate: This is not appropriate, as the nursing student may not be trained in medical terminology or confidentiality, which could lead to miscommunication and potential breaches of privacy.

B. Allow the client's partner to translate: While the partner may understand the language, this approach can create conflicts of interest, and they may not be able to convey the full medical context or sensitive information accurately.

C. Request a female interpreter through the facility: This is the best action. Using a trained, professional interpreter ensures that the communication is accurate and confidential, allowing the nurse to gather necessary admission data effectively while respecting the client's comfort and cultural needs.

D. Have the client's child translate: It is not appropriate to involve a child in medical discussions, as they may not fully understand the context or terminology and could feel overwhelmed by the responsibility.

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A nurse is preparing to perform a sterile dressing change. Which of the following actions should the nurse take when setting up the sterile field?

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Naxlex Comprehensive Predictor Exams

A nurse is developing a plan of care for a newborn whose mother tested positive for heroin during pregnancy. The newborn is experiencing neonatal abstinence syndrome. Which of the following actions should the nurse include in the plan?

Correct Answer is C

Explanation

Correct Answer is C

Explanation

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