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 B
Explanation
Choice A) Antihypertensive: This is not the correct classification of magnesium sulfate. Antihypertensives are drugs that lower blood pressure, such as beta blockers, calcium channel blockers, or angiotensin-converting enzyme inhibitors. Magnesium sulfate does not have a significant effect on blood pressure, and it is not used as a primary treatment for hypertension in preeclampsia.
Choice B) Anticonvulsant: This is the correct classification of magnesium sulfate. Anticonvulsants are drugs that prevent or reduce the frequency and severity of seizures, such as phenytoin, valproic acid, or carbamazepine.
Magnesium sulfate is used as a prophylactic and therapeutic agent for eclampsia, which is a life-threatening complication of preeclampsia characterized by seizures. Magnesium sulfate acts by blocking the neuromuscular transmission and reducing the cerebral edema and vasospasm.
Choice C) Tocolytic: This is not the correct classification of magnesium sulfate. Tocolytics are drugs that inhibit uterine contractions and delay preterm labor, such as terbutaline, nifedipine, or indomethacin. Magnesium sulfate is not effective as a tocolytic agent, and it is not recommended for this purpose by the American College of Obstetricians and Gynecologists.
Choice D) Diuretic: This is not the correct classification of magnesium sulfate. Diuretics are drugs that increase urine output and reduce fluid retention, such as furosemide, hydrochlorothiazide, or spironolactone. Magnesium sulfate does not have a diuretic effect, and it can cause fluid overload and pulmonary edema if administered in excess.
Correct Answer is C
Explanation
Choice A) Newborns are abdominal breathers is incorrect because this is not a reason why the respiratory rate should be counted for a complete minute, but rather a characteristic of how newborns breathe. Abdominal breathing means that the diaphragm and the abdominal muscles are the main muscles used for breathing, rather than the chest muscles. Newborns are abdominal breathers because their chest wall is more compliant and less stable than adults, and their intercostal muscles are not fully developed. Abdominal breathing does not affect the accuracy or duration of measuring the respiratory rate, as long as the abdomen is visible and palpable. Therefore, this response is irrelevant and inaccurate.
Choice B) Activity will increase the respiratory rate is incorrect because this is not a reason why the respiratory rate should be counted for a complete minute, but rather a factor that can influence the respiratory rate. Activity means any physical or mental exertion that requires more oxygen and energy from the body. Activity can increase the respiratory rate, as well as the heart rate and blood pressure, to meet the increased oxygen demand and carbon dioxide removal. However, activity does not affect the accuracy or duration of measuring the respiratory rate, as long as the newborn is calm and resting during the measurement. Therefore, this response is irrelevant and inaccurate.
Choice C) The rate and rhythm of breath are irregular in newborns is correct because this is a reason why the respiratory rate should be counted for a complete minute. The rate and rhythm of breath refer to how fast and how regularly one breathes. Newborns have an irregular rate and rhythm of breath, which means that they breathe at different speeds and intervals, sometimes pausing for a few seconds between breaths. This is normal and harmless for newborns, as long as they do not stop breathing for more than 20 seconds or show signs of distress. However, it can make it difficult to measure the respiratory rate accurately, as counting for a shorter period may not reflect the true average rate. Therefore, counting for a complete minute can ensure a more reliable measurement. Therefore, this response is clear and accurate.
Choice D) Newborns do not expand their lungs fully with each respiration is incorrect because this is not a reason why the respiratory rate should be counted for a complete minute, but rather a feature of how newborns breathe.
Lung expansion means how much air one inhales and exhales with each breath. Newborns do not expand their lungs fully with each respiration, because they have smaller lung volumes and capacities than adults, and they breathe more shallowly and rapidly. However, lung expansion does not affect the accuracy or duration of measuring the respiratory rate, as long as the chest or abdomen movement is visible and palpable. Therefore, this response is irrelevant and inaccurate.
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