A nurse is preparing a sterile field for a client who requires a dressing change. Which of the following actions should the nurse plan to take?

Drop the sterile gauze from 25.4 cm (10 in) above the sterile field.

Hold the sterile package in his dominant hand and open the top flap of the package toward his body.

Place objects 1.27 cm (0.5 in) inside the border of the sterile field.

Position the bottle outside the edge of the sterile field when pouring solution into a sterile container.

Answer and Explanation

The Correct Answer is A

Rationale:

A. Drop the sterile gauze from 25.4 cm (10 in) above the sterile field: Dropping sterile items from a height of about 6 to 12 inches prevents contamination by keeping hands outside the sterile field and ensuring the item lands safely without touching nonsterile surfaces.

B. Hold the sterile package in his dominant hand and open the top flap of the package toward his body: The top flap should be opened away from the nurse’s body to maintain sterility and prevent the arm from crossing over the sterile field, which would risk contamination.

C. Place objects 1.27 cm (0.5 in) inside the border of the sterile field: The outer 2.5 cm (1 inch) of the sterile field is considered contaminated. Placing items only 0.5 inches inside this border would place them within the contaminated zone, risking sterile field compromise.

D. Position the bottle outside the edge of the sterile field when pouring solution into a sterile container: While the bottle should not touch the sterile field, it must be close enough to pour without splashing, and the sterile container must be inside the sterile field.

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Correct Answer is A

Explanation

Rationale:

A. "Your family disagrees with your decision?": This open-ended response reflects therapeutic communication by encouraging the client to express her feelings without judgment. It invites further discussion and shows the nurse’s support for the client’s autonomy and emotional well-being.

B. "Did you tell your provider that your family doesn't agree with your decision?": This response shifts focus away from the client's emotional conflict and places it on the provider. It may dismiss the client’s current need for support and hinder further emotional exploration.

C. "You are making the same decision I would make.": Personalizing the conversation undermines client autonomy. The nurse’s role is to support the client’s decision-making process, not impose personal opinions or make assumptions about what is best.

D. "You should get your family to agree with your decision before signing the consent.": This response suggests the client must yield to family opinions, which contradicts the principle of informed consent. The decision is ultimately the client’s, and family agreement is not a legal or ethical requirement.

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}

Explanation

Rationale for correct choices:

Macrosomia: Post-term infants (≥42 weeks gestation) have prolonged exposure to intrauterine nutrients, increasing the risk of excessive fetal growth. Macrosomia is common and can lead to complications such as shoulder dystocia or birth trauma.
Meconium aspiration syndrome: As gestation progresses beyond term, placental function may decline, increasing fetal stress. This can trigger passage of meconium in utero and aspiration during delivery, especially with late decelerations suggesting uteroplacental insufficiency.

Rationale for incorrect choices:

Intraventricular hemorrhage: This condition is typically associated with preterm infants due to fragile cerebral vasculature. A post-term newborn is not at increased risk for IVH.
Bronchopulmonary dysplasia: BPD is a chronic lung disease most often seen in premature infants requiring prolonged mechanical ventilation and oxygen therapy. It is not a common concern for post-term infants.

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A nurse is preparing a sterile field for a client who requires a dressing change. Which of the following actions should the nurse plan to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

A nursery nurse is attending the birth of a post-term infant Exhibits Fill in each blank in the following sentence. Upon review of the medical record, the nurse should determine the infant newborn is at risk for developing dropdown and dropdown.

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}

Explanation

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