An unlicensed assistive personnel (UAP) applies a pediatric urine collection (PUC) bag on the symphysis pubis of a female infant.
Which action is most important for the practical nurse (PN) to take when checking the placement of the PUC bag?
Apply a dry diaper over the PUC bag.
Ensure the bag's adhesive is secured to the true perineum.
Calculate the infant's fluid intake.
Ask the mother when the infant previously voided.
The Correct Answer is B
Choice A rationale
Applying a dry diaper over the PUC bag is a routine step after placement but is not the most important action for checking placement. While necessary for hygiene and containing urine, it does not directly verify the correct anatomical positioning of the collection bag, which is crucial for accurate and contamination-free urine collection in infants.
Choice B rationale
Ensuring the bag's adhesive is secured to the true perineum is the most critical action. Proper placement on the true perineum (the anatomical region between the thighs, encompassing the anus and external genitalia) ensures that urine directly enters the collection bag, preventing contamination from stool or skin flora, and allowing for an accurate and sterile urine sample.
Choice C rationale
Calculating the infant's fluid intake is a separate nursing responsibility related to overall fluid balance and hydration status. It is not directly related to checking the correct placement of a pediatric urine collection bag. While fluid intake influences urine output, it does not provide information about the anatomical accuracy of the bag's application.
Choice D rationale
Asking the mother when the infant previously voided provides historical information about the infant's voiding pattern. While helpful for anticipating when the infant might void again, this information does not confirm the current, proper placement of the urine collection bag. The physical verification of adhesive placement is paramount for effective collection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["25"]
Explanation
Step 1 is: Subtract the dry diaper weight from the wet diaper weight to find the weight of the urine. 75 grams - 50 grams = 25 grams.
Step 2 is: Convert the weight of the urine from grams to milliliters, as 1 gram of urine is approximately equal to 1 mL. 25 grams = 25 mL. The urine output is 25 mL.
Correct Answer is D
Explanation
Choice A rationale
Washing frequently with mild soap and water is not recommended for umbilical cord care because soap can irritate the delicate skin around the cord stump and potentially delay the natural drying and separation process. Excessive moisture also increases the risk of bacterial colonization and infection, counteracting the goal of keeping the area clean and dry to promote healing and reduce infection risk.
Choice B rationale
Applying baby lotion to the umbilical cord stump is contraindicated. Lotions introduce moisture, which can impede the natural drying and mummification of the cord, prolonging the time until it falls off. Furthermore, lotions contain chemicals that may irritate the sensitive skin or harbor bacteria, increasing the risk of infection and delaying proper healing of the umbilical area.
Choice C rationale
Covering the umbilical cord with a sterile dressing is generally not advised unless specifically indicated by a healthcare provider for a particular condition. A dressing can trap moisture, preventing adequate air circulation needed for drying, and potentially create a warm, moist environment conducive to bacterial growth. This increases the risk of infection and delays natural cord separation.
Choice D rationale
Cleaning the umbilical cord with water and allowing it to air dry is the most evidence-based practice for routine cord care. Water gently removes any discharge without irritating the skin, and air exposure facilitates the drying process, which is crucial for mummification and eventual detachment. This minimizes the risk of infection and promotes natural healing.
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