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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A) Monitor uterine contractions is incorrect because this is not the most urgent intervention for a pregnant woman who has experienced a bleeding episode in late pregnancy. Uterine contractions can indicate labor or placental abruption, which are possible causes of bleeding in late pregnancy. However, they are not the only or the most reliable indicators of these conditions, as some women may have painless bleeding or contractions without bleeding. Moreover, monitoring uterine contractions does not address the immediate needs of the mother and the fetus, such as oxygenation, circulation, and perfusion. Therefore, this intervention should be done after assessing and stabilizing the vital signs and FHR.
Choice B) Assess fetal heart rate (FHR) and maternal vital signs is correct because this is the most important and essential intervention for a pregnant woman who has experienced a bleeding episode in late pregnancy. Bleeding in late pregnancy can be caused by various conditions, such as placenta previa, placental abruption, uterine rupture, or vasa previa, which can compromise the blood supply and oxygen delivery to the mother and the fetus. Assessing FHR and maternal vital signs can help to determine the severity and cause of the bleeding, as well as guide further
interventions such as fluid resuscitation, oxygen therapy, blood transfusion, or emergency delivery. The normal FHR range for a fetus is 110 to 160 beats per minute, and it may vary with fetal activity or maternal position. The normal maternal vital signs are: blood pressure 120/80 mm Hg or lower, heart rate 60 to 100 beats per minute, respiratory rate 12 to 20 breaths per minute, and temperature 36.5°C to 37.5°C (97.7°F to 99.5°F). Any deviation from these ranges may indicate hypoxia, hypovolemia, shock, infection, or distress. Therefore, this intervention should be done as soon as possible for women who have bleeding in late pregnancy.
Choice c) Perform a venipuncture for hemoglobin and hematocrit levels is incorrect because this is not a priority intervention for a pregnant woman who has experienced a bleeding episode in late pregnancy. Hemoglobin and hematocrit are blood tests that measure the amount of red blood cells and their percentage in the blood volume.
They can help to evaluate the extent of blood loss and the need for blood transfusion. However, they are not
immediate or accurate indicators of bleeding in late pregnancy, as they may take time to reflect the changes in blood volume or be affected by other factors such as hydration or hemodilution. Moreover, performing a venipuncture does not address the immediate needs of the mother and the fetus, such as oxygenation, circulation, and perfusion.
Therefore, this intervention should be done after assessing and stabilizing the vital signs and FHR.
Choice d) Place clean disposable pads to collect any drainage is incorrect because this is not a priority intervention for a pregnant woman who has experienced a bleeding episode in late pregnancy. Placing clean disposable pads can help to keep the perineal area clean and dry, as well as to estimate the amount and type of bleeding. However, it does not address the immediate needs of the mother and the fetus, such as oxygenation, circulation, and perfusion. Moreover, it does not provide any information about the cause or severity of the bleeding, as it may be affected by factors such as gravity or pooling. Therefore, this intervention should be done after assessing and stabilizing the vital signs and FHR.
Correct Answer is B
Explanation
Choice a) 100 to 120 is incorrect because this is too low for a normal newborn's heart rate. The heart rate of a newborn is influenced by factors such as gestational age, activity level, temperature, and health status. A full-term, quiet, alert newborn should have a heart rate between 120 and 160 beats per minute, which reflects their high metabolic rate and oxygen demand. A heart rate below 100 beats per minute may indicate bradycardia, which can be caused by hypoxia, hypothermia, or cardiac problems.
Choice b) 120 to 160 is correct because this is the normal range for a full-term, quiet, alert newborn's heart rate. The apical pulse is the best way to measure the heart rate of a newborn, as it reflects the actual contractions of the heart. The apical pulse can be auscultated at the fourth intercostal space on the left side of the chest, just below the nipple line. The nurse should count the apical pulse for a full minute, as it may vary with the respiratory cycle.
Choice c) 80 to 100 is incorrect because this is also too low for a normal newborn's heart rate. A full-term, quiet, alert newborn should have a heart rate between 120 and 160 beats per minute, which is higher than that of an adult or an older child. A heart rate below 100 beats per minute may indicate bradycardia, which can be caused by hypoxia, hypothermia, or cardiac problems.
Choice d) 150 to 180 is incorrect because this is too high for a normal newborn's heart rate. A full-term, quiet, alert newborn should have a heart rate between 120 and 160 beats per minute, which is lower than that of a preterm or a crying newborn. A heart rate above 160 beats per minute may indicate tachycardia, which can be caused by fever, infection, anemia, or hyperthyroidism.
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