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?

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

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.

Answer and Explanation

The Correct Answer is D

A: The sterile field should be set up at or above waist level to prevent contamination from higher surfaces, not below.
B: The outer edge (about 2.5 cm or 1 inch) of the sterile field is considered non-sterile, so placing the sterile dressing close to the edge risks contamination.

C: The outermost flap of the sterile kit should be opened away from the body to avoid reaching over the sterile field, which could lead to contamination.
D: The cap should be placed sterile side up to maintain its sterility if it needs to be reapplied to the solution bottle.

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Correct Answer is C

Explanation

A. Using up to 40 nicotine lozenges per day is excessive and may lead to nicotine toxicity.

B. Substituting tobacco use with an electronic cigarette is not recommended due to potential health risks associated with vaping.
C. Nicotine replacement therapy, such as nicotine gum, should be used for a limited duration to avoid dependence. The nurse should educate the client to limit the use of nicotine gum to no more than 6 months to achieve smoking cessation goals effectively.
D. Using progressively larger nicotine patches is not a standard practice and may increase the risk of nicotine overdose.

A. Evaluate uterine tone. B. Loosely wrap the cord with petroleum gauze. C. Place the client in Trendelenburg position. D. Apply fundal pressure.

Correct Answer is C

Explanation

A. While evaluating uterine tone is part of routine labor monitoring, it does not address the urgent need to relieve pressure on the prolapsed umbilical cord.

B. Keeping the cord moist is less of a priority than immediate measures to relieve pressure on the cord.
C. For a prolapsed umbilical cord, the immediate goal is to relieve pressure on the cord to maintain fetal oxygenation. Placing the client in the Trendelenburg position or a knee-to-chest position can help reduce the pressure on the cord by using gravity to shift the fetal presenting part toward the diaphragm.
D. Applying fundal pressure is contraindicated in the case of umbilical cord prolapse as it can increase pressure on the cord and exacerbate fetal distress.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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