A nurse is performing hand hygiene after caring for a client who has Clostridium difficile. Which of the following cleansing agents should the nurse use?

A) A newborn has an Apgar score of 7 at 5 min after birth:

An Apgar score of 7 at 5 minutes after birth is within the expected range and does not require an incident report. Apgar scores are used to assess a newborn's overall condition at birth, and a score of 7 indicates the infant is in good condition.

B) A newborn has respiratory distress and requires oxygen:

This event warrants completing an incident report because respiratory distress in a newborn requiring oxygen may indicate a significant clinical issue that needs to be investigated further. An incident report allows for documentation and investigation of the event to ensure appropriate actions are taken to address the newborn's condition and prevent similar incidents in the future.

C) A newborn receives erythromycin ophthalmic ointment 4 hr after birth:

Administering erythromycin ophthalmic ointment to newborns is a routine procedure to prevent ophthalmia neonatorum and does not require an incident report unless there is an adverse reaction or error in administration.

D) A newborn receives a heel stick on the outer aspect of the heel:

Heel sticks are commonly performed for newborn screening tests, such as blood glucose or bilirubin levels. Unless there is an error in the procedure or an adverse event related to the heel stick, it does not necessitate an incident report.

A) Tying the restraint to the bed frame: This action is appropriate and ensures that the restraint is anchored securely to the bed frame, preventing the client from removing it independently. Tying the restraint to the bed frame is a standard practice to maintain the client's safety.

B) Applying the restraint over the client's gown: While it's generally preferable to apply restraints directly to the client's skin to minimize movement and ensure effectiveness, applying the restraint over the gown is acceptable in some situations. However, it's essential to ensure that the restraint is snug and properly secured to prevent the client from slipping out of it.

C) Placing the restraint across the client's chest: Placing the restraint across the client's chest is not recommended because it can restrict chest expansion and interfere with breathing, potentially leading to respiratory compromise. Restraints should be applied to minimize movement while allowing the client to breathe comfortably.

D) Using a quick-release knot to secure the restraint: Using a quick-release knot is essential when applying restraints to ensure that they can be quickly removed in case of an emergency or if the client experiences distress. This promotes client safety and allows for rapid intervention if needed.