The student nurse asks why gloves are needed when handling a newborn because the newborn "hasn't been exposed to anything". What response by the nurse is best?
We are protecting the infant from our bacteria.
Amniotic fluid and maternal blood pose risks to us.
It is hospital policy.
It is part of standard precautions.
The Correct Answer is D
Choice a) We are protecting the infant from our bacteria is incorrect because this is not the main reason why gloves are needed when handling a newborn. While it is true that newborns have immature immune systems and are susceptible to infections, gloves are not only used to protect the infant from our bacteria but also to protect ourselves from the infant's body fluids and secretions, which may contain pathogens or blood-borne diseases.
Therefore, this response is incomplete and misleading.
Choice b) Amniotic fluid and maternal blood pose risks to us is incorrect because this is also not the primary reason why gloves are needed when handling a newborn. While it is true that amniotic fluid and maternal blood may contain harmful microorganisms or viruses that can infect us, gloves are not only used to protect ourselves from these substances but also to protect the infant from our skin flora and potential contaminants, which may cause skin irritation or infection. Therefore, this response is also incomplete and misleading.
Choice c) It is hospital policy is incorrect because this is not a sufficient or satisfactory reason why gloves are needed when handling a newborn. While it is true that wearing gloves may be a hospital policy or protocol, this response does not explain the rationale or evidence behind this policy and may imply that the nurse does not understand or agree with it. Therefore, this response is vague and unprofessional.
Choice d) It is part of standard precautions is correct because this is the best and most accurate reason why gloves are needed when handling a newborn. Standard precautions are a set of guidelines and practices that aim to prevent the transmission of infections in healthcare settings. They include wearing gloves, gowns, masks, and eye protection when there is a risk of exposure to blood or body fluids, as well as washing hands before and after patient contact, cleaning and disinfecting equipment and surfaces, and disposing of waste properly. Standard precautions apply to all patients, regardless of their diagnosis or infection status, and are based on the principle that all blood and body fluids are potentially infectious. Therefore, this response is clear and appropriate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice a) Check the baby's diaper is incorrect because this is not a priority action for a baby who is grunting in the neonatal nursery. Grunting is a sign of respiratory distress, which means that the baby is having difficulty breathing and is trying to keep air in the lungs by making a low-pitched sound with each expiration. Checking the baby's diaper may be part of routine care, but it does not address the underlying cause of the grunting or improve the baby's oxygenation. Therefore, this action should be done after assessing and treating the baby's respiratory status.
Choice b) Place a pacifier in the baby's mouth is incorrect because this is not an appropriate action for a baby who is grunting in the neonatal nursery. Grunting is a sign of respiratory distress, which means that the baby is having difficulty breathing and is trying to keep air in the lungs by making a low-pitched sound with each expiration. Placing a pacifier in the baby's mouth may interfere with the baby's breathing and worsen the grunting, as it can obstruct the airway, increase the work of breathing, or cause aspiration. Therefore, this action should be avoided or used with caution for babies who are grunting.
Choice c) Have the mother feed the baby is incorrect because this is not a safe action for a baby who is grunting in the neonatal nursery. Grunting is a sign of respiratory distress, which means that the baby is having difficulty breathing and is trying to keep air in the lungs by making a low-pitched sound with each expiration. Having the mother feed the baby may increase the risk of choking or aspiration, as the baby may not be able to coordinate sucking, swallowing, and breathing. Therefore, this action should be delayed or modified until the baby's respiratory status improves.
Choice d) Assess the respiratory rate is correct because this is the most important action for a baby who is grunting in the neonatal nursery. Grunting is a sign of respiratory distress, which means that the baby is having difficulty breathing and is trying to keep air in the lungs by making a low-pitched sound with each expiration. Assessing the respiratory rate can help to determine the severity and cause of the respiratory distress, as well as guide further interventions such as oxygen therapy, suctioning, or medication. The normal respiratory rate for a newborn ranges from 30 to 60 breaths per minute, and it may vary with sleep or activity. A respiratory rate above 60 breaths per minute or below 30 breaths per minute indicates abnormality and requires immediate attention. Therefore, this action should be done as soon as possible for babies who are grunting.
Correct Answer is D
Explanation
Choice A: This is incorrect because weight less than the 10th percentile (SGA) means that the infant is smaller than expected for the gestational age, but not necessarily low birth weight. SGA infants may have intrauterine growth restriction due to maternal, placental, or fetal factors, but they may also be constitutionally small. SGA infants are at risk for hypoglycemia, hypothermia, polycythemia, and perinatal asphyxia.
Choice B: This is incorrect because weight greater than the 90th percentile means that the infant is larger than expected for the gestational age, but not necessarily high birth weight. Infants with weight greater than the 90th percentile are called large for gestational age (LGA) or macrosomic. LGA infants may have maternal diabetes, genetic factors, or post-term pregnancy as causes, but they may also be constitutionally large. LGA infants are at risk for birth trauma, shoulder dystocia, hypoglycemia, and respiratory distress.
Choice C: This is incorrect because weight between the 10th and 90th percentile means that the infant is appropriate for the gestational age (AGA), but not necessarily normal birth weight. AGA infants have a weight that matches their gestational age and are considered healthy and well-nourished. However, some AGA infants may have low or high birth weight depending on their gestational age at birth.
Choice D: This is the correct answer because low birth weight (LBW) is defined as a weight of 2500g or less at birth, regardless of the gestational age. LBW infants may be preterm (born before 37 weeks of gestation), term (born between 37 and 42 weeks of gestation), or post-term (born after 42 weeks of gestation). LBW infants are at risk for infection, bleeding, jaundice, and neurodevelopmental problems.
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