A nurse is reviewing standard precautions with an assistive personnel (AP) who is new to the newborn nursery. For which of the following newborn care procedures should the nurse remind the AP to wear clean gloves?
Removing a mask after phototherapy
Applying an identification bracelet
Measuring axillary temperature
Changing wet diapers
The Correct Answer is D
A. Removing a mask after phototherapy: Removing a mask after phototherapy does not involve contact with bodily fluids or potentially contaminated surfaces. Clean gloves are not required for this activity because the risk of transmission is minimal.
B. Applying an identification bracelet: Applying a bracelet involves only superficial contact with the newborn’s skin and does not pose a risk of exposure to blood or body fluids. Standard hand hygiene is sufficient; gloves are not needed.
C. Measuring axillary temperature: Taking an axillary temperature involves minimal contact with the skin and does not expose the AP to blood or body fluids. Clean gloves are not necessary for this procedure unless there is visible soiling or open lesions.
D. Changing wet diapers: Diaper changes involve direct contact with urine and feces, which are potential sources of pathogens. Wearing clean gloves protects the AP from contamination and helps prevent the spread of infection, making glove use essential for this procedure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Position the seat of the wheelchair at a right angle to the bed: Proper wheelchair positioning is important to facilitate a safe pivot transfer and reduce the distance the client must move. However, ensuring environmental safety by stabilizing equipment must occur before positioning. The wheelchair can be placed correctly after confirming both surfaces are secure.
B. Lock the wheels on the bed: Safety is the priority before initiating any transfer. Locking the wheels on the bed prevents unintended movement that could result in loss of balance or falls, particularly in a client with unilateral weakness. Stabilizing the bed establishes a secure foundation prior to assisting the client to sit or stand.
C. Have the client sit at the edge of the bed: Dangling at the bedside allows assessment for orthostatic hypotension and balance, but this step should occur only after ensuring the bed is secure. Assisting the client to sit before locking the wheels increases fall risk if the bed shifts.
D. Place a gait belt around the client's waist: A gait belt enhances stability and control during transfer, especially for a client with left-sided weakness. However, it is applied after environmental safety measures, such as locking the bed and wheelchair, are completed.
Correct Answer is B
Explanation
A. Tell the children to alternate standing on one foot and observe their balance: Assessing balance does not evaluate spinal curvature or detect scoliosis. While balance testing may identify neuromuscular issues, it is not part of standard scoliosis screening and does not reveal lateral spinal deviations.
B. Ask the children to bend forward at the waist and observe them from behind: The forward bend (Adam’s forward bend) test is the recommended screening method for scoliosis. Observing from behind allows the nurse to detect asymmetry in the shoulders, ribs, or hips, which may indicate spinal curvature. This method is simple, noninvasive, and effective for early detection.
C. Tell the children to stand up straight and observe them facing forward: Viewing the child from the front while standing upright may reveal gross asymmetry but is less sensitive than the forward bend test. Subtle spinal curvatures are often not noticeable when the child is standing upright.
D. Ask the children to raise their hands over their head and turn from side to side: Raising arms and twisting does not provide clear visualization of spinal asymmetry. Scoliosis screening relies on observing the alignment of the spine and rib cage during forward flexion, not rotational movements.
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