While performing a routine assessment, a nurse notices fraying on the electrical cord of a client’s continuous passive motion (CPM) device.
Which of the following actions should the nurse take first?

The correct answer is c. Remove the cap and place it sterile-side up on a clean surface.

Choice A rationale:

Placing sterile gauze over areas of spilled solution within the sterile field is incorrect. If solution is spilled within the sterile field, the entire field should be considered contaminated and a new sterile field should be set up

Choice B rationale:

Holding the irrigation solution bottle with the label facing away from the palm of the hand is incorrect. The label should face the palm of the hand to avoid contamination of the sterile field

Choice C rationale:

Removing the cap and placing it sterile-side up on a clean surface is correct. This ensures that the sterile side of the cap remains sterile and can be used to recap the bottle after pouring the solution

Choice D rationale:

Holding the bottle in the center of the sterile field when pouring the solution is incorrect. The bottle should be held over the edge of the sterile field to avoid contamination of the field if solution spills

Determine the client’s knowledge about diaphragm use. This is the first action the nurse should take because it allows the nurse to assess the client’s readiness to learn, identify any knowledge gaps, and tailor the teaching to the client’s needs.

Some of the other choices are wrong because:

Choice A is wrong because Supervise return demonstration of diaphragm use.

This is not the first action the nurse should take because it assumes that the client already knows how to use the diaphragm correctly and safely. The nurse should first teach the client how to insert, remove, and care for the diaphragm before asking for a return demonstration.

Choice C is wrong because Document the client’s level of understanding about potential adverse effects.

This is not the first action the nurse should take because it is part of the evaluation phase of teaching, not the assessment phase. The nurse should first determine what the client knows and needs to know about diaphragm use and its possible risks and benefits.

Choice D is wrong because Teach the client how to insert the diaphragm.

This is not the first action the nurse should take because it is part of the implementation phase of teaching, not the assessment phase. The nurse should first assess the client’s knowledge, motivation, and preferences before providing instruction on how to use the diaphragm.

A contraceptive diaphragm is a birth control device that prevents sperm from entering the uterus.

It is a small, soft silicone or rubber cup with a flexible rim that covers the cervix.

It is inserted into the vagina with spermicide before sex and is held in place by the pelvic muscles. It is a reusable type of contraception that women can use to avoid getting pregnant.