A nurse is collecting a urine specimen for culture and sensitivity from a client who has an indwelling urinary catheter.
Which of the following actions should the nurse take?

Choice A rationale

A small amount of liquid stool draining from the stoma is expected during the early postoperative period following colostomy placement. This indicates that the stoma is functioning and passing waste as intended.

Choice B rationale

The stoma protruding slightly from the abdomen, known as stoma protrusion or eversion, is a common and normal finding. It indicates that the stoma is correctly positioned and healing properly.

Choice C rationale

A dark-colored stoma is a concerning sign that indicates compromised blood flow to the stoma tissue, potentially leading to necrosis. This requires immediate medical attention to address the underlying cause and prevent further complications.

Choice D rationale

Light bleeding from the stoma when touched is normal in the immediate postoperative period. The stoma tissue is highly vascular, and minor bleeding is expected as it heals and forms new tissue connections.

Choice A rationale

Placing one hand over the other against the upper body of the gown increases the risk of contamination. The sterile field must be maintained by keeping hands in a position where they are less likely to come into contact with non-sterile surfaces.

Choice B rationale

Clasping hands behind the body at the waist can also lead to contamination, as the hands may inadvertently touch the gown, which may not be sterile in that area. It’s essential to keep hands in a position where they are less likely to become contaminated.

Choice C rationale

Keeping arms at the sides with hands in a relaxed position might cause hands to brush against non-sterile surfaces or clothing, leading to contamination. Therefore, this position is not recommended for maintaining sterility.

Choice D rationale

Interlocking fingers and holding hands away from the body above the waist is the proper technique for maintaining sterility. This position ensures that the hands are kept in the sterile field and away from non-sterile surfaces, reducing the risk of contamination.