A nurse is setting up a sterile field to perform wound irrigation for a client. Which of the following actions should the nurse take when pouring the sterile solution?

Place sterile gauze over areas of spilled solution within the sterile field.

Hold the irrigation solution bottle with the label facing away from the palm of the hand.

Remove the cap and place it sterile-side up on a clean surface.

Hold the bottle in the center of the sterile field when pouring the solution.

Answer and Explanation

The Correct Answer is C

The correct answer is choice 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 not recommended. Spilled solution can compromise the sterility of the field, and covering it with gauze does not restore sterility. Instead, the nurse should avoid spilling solution to maintain the sterile field.

Choice B rationale:

Holding the irrigation solution bottle with the label facing away from the palm of the hand is incorrect. The correct technique is to hold the bottle with the label facing the palm. This prevents the label from getting wet and unreadable, ensuring that the nurse can always identify the solution correctly.

Choice C rationale:

Removing the cap and placing it sterile-side up on a clean surface is the correct action. This maintains the sterility of the cap, preventing contamination when it is replaced on the bottle. Ensuring the cap remains sterile is crucial for maintaining the sterility of 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 outside the sterile field to prevent contamination. The solution should be poured carefully to avoid splashing and compromising the sterile field.

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Correct Answer is A

Explanation

The correct answer is choice A, administer a fluid bolus.

Choice A rationale:

Administering a fluid bolus is appropriate when a client’s urine output is low, which in this case is less than the minimum expected output of 30 mL/hr. The dark yellow color of the urine also suggests dehydration or concentrated urine, which can be addressed with increased fluid intake.

Choice B rationale:

Initiating continuous bladder irrigation is typically done to clear the urinary tract of blood clots or debris following urologic surgery, not for low urine output or dark urine. Therefore, this intervention is not indicated based on the given scenario.

Choice C rationale:

Obtaining a urine specimen for culture and sensitivity is an action taken when there is a suspicion of a urinary tract infection. The scenario does not provide evidence of infection, such as fever or cloudy urine with a strong odor, so this would not be the first intervention to anticipate.

Choice D rationale:

Clamping the catheter tubing is done in preparation for catheter removal or to assess if the client can void without the catheter. It is not an appropriate intervention for low urine output or dark urine and could potentially cause bladder distention or discomfort.

A. Maternal hypoglycemia. B. Maternal fever. C. Chorioamnionitis. D. Fetal anemia.

Correct Answer is A

Explanation

The correct answer is choice a. Maternal hypoglycemia.

Choice A rationale:

Maternal hypoglycemia can lead to fetal bradycardia, causing a sustained low fetal heart rate. Hypoglycemia in the mother can affect the fetus by reducing the availability of glucose, which is essential for fetal metabolism and heart function.

Choice B rationale:

Maternal fever is more commonly associated with fetal tachycardia rather than bradycardia. Fever in the mother can lead to an increased fetal heart rate, not a decreased one.

Choice C rationale:

Chorioamnionitis is an infection of the fetal membranes and amniotic fluid, which can lead to fetal distress and tachycardia rather than bradycardia.

Choice D rationale:

Fetal anemia can also cause bradycardia, but in this scenario, maternal hypoglycemia is a more immediate concern as it directly affects the fetal heart rate by impacting the fetal metabolic processes.

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A nurse is setting up a sterile field to perform wound irrigation for a client. Which of the following actions should the nurse take when pouring the sterile solution?

Choice A rationale:

Choice B rationale:

Choice C rationale:

Choice D rationale:

Nursing Test Bank

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