What action by the nurse is the most important action in preventing neonatal infection?

Standard Precautions

Good hand hygiene

Separate gown technique

Isolation of infected infants

Answer and Explanation

The Correct Answer is B

Choice A: This is incorrect because Standard Precautions are a set of guidelines that apply to all patients, regardless of their infection status. They include using personal protective equipment, handling sharps and waste properly, and cleaning and disinfecting equipment and surfaces. However, they are not enough to prevent neonatal infection, as some pathogens can still be transmitted by contact or droplet.

Choice B: This is the correct answer because good hand hygiene is the most effective way to prevent the transmission of microorganisms that can cause neonatal infection. The nurse should wash their hands with soap and water or use an alcohol-based hand rub before and after touching the infant, the infant's environment, or any items that come in contact with the infant. The nurse should also educate the parents and visitors on the importance of hand hygiene and how to perform it correctly.

Choice C: This is incorrect because a separate gown technique involves wearing a clean gown for each infant and discarding it after use. This can help prevent cross-contamination between infants, but it does not eliminate the need for hand hygiene. The nurse should still wash their hands before and after wearing a gown, as well as before and after touching the infant or any items that come in contact with the infant.

Choice D: This is incorrect because isolation of infected infants involves placing them in a separate room or area with restricted access and using additional precautions based on the mode of transmission of the infection. This can help prevent the spread of infection to other infants, staff, or visitors, but it does not eliminate the need for hand hygiene. The nurse should still wash their hands before and after entering and leaving the isolation area, as well as before and after touching the infant or any items that come in contact with the infant.

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Correct Answer is D

Explanation

Choice A: This is incorrect because pointing out how lucky she is to have a healthy baby may invalidate her feelings and make her feel guilty or ashamed. The nurse should acknowledge and respect the client's emotions and avoid making judgments or comparisons.

Choice B: This is incorrect because assessing her for pain is not the first action that the nurse should take. Although pain may be a factor that contributes to the client's emotional state, it is not the primary cause of her crying. The nurse should first establish rapport and trust with the client and then assess her physical and psychological needs.

Choice C: This is incorrect because explaining that she is experiencing postpartum blues may be premature and inaccurate. Postpartum blues are mild and transient mood changes that occur in up to 80% of women within the first few days after childbirth. They are characterized by tearfulness, irritability, anxiety, and mood swings. However, the nurse should not assume that the client has postpartum blues without performing a thorough assessment and ruling out other possible causes of her crying, such as postpartum depression, anxiety, or trauma.

Choice D: This is the correct answer because allowing her time to express her feelings is the most appropriate and empathetic action that the nurse should take first. The nurse should listen actively and attentively to the client and provide emotional support and reassurance. The nurse should also use open-ended questions and reflective statements to facilitate communication and explore the client's concerns and coping strategies.

A. Check the baby's diaper. B. Place a pacifier in the baby's mouth. C. Have the mother feed the baby. D. Assess the respiratory rate.

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.

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What action by the nurse is the most important action in preventing neonatal infection?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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