Skills Lab 101 & 101a

The aseptic technique is used to prevent infection. When cleaning the infant's umbilical cord, it is important to maintain a sterile environment to minimize the risk of introducing bacteria or other pathogens that could cause an infection. By following aseptic technique, healthcare professionals can reduce the likelihood of complications and promote the infant's overall health and well-being.

Based on the given information, Celine's last menstrual period was on November 3, 2008. To calculate her estimated due date (EDD), we need to add 280 days (approximately 40 weeks) to the first day of her last menstrual period. Adding 280 days to November 3, 2008, the estimated due date would be August 10, 2009.

In this scenario, the nurse is preparing for catheterization for a patient undergoing a caesarian section. Catheterization is an invasive procedure that requires a sterile technique to minimize the risk of infection. Using sterile technique involves maintaining a sterile field, using sterile gloves, and using sterile equipment to prevent the introduction of microorganisms. This is especially important in surgical settings where the risk of infection is higher. Therefore, the nurse should prepare for catheterization using sterile technique.

Positioning the female patient in a supine position with knees flexed about two feet apart is the correct answer for catheter insertion. This position allows for better access to the urethra and easier insertion of the catheter. The flexed knees help to relax the pelvic muscles and provide a more comfortable position for the patient during the procedure. The two feet apart position allows for better visualization and access to the perineal area, making the catheter insertion easier and more successful.

The correct answer is 1-2 inches because lubricating the catheter helps to ease its insertion into the patient's body. Lubricating only 1-2 inches of the catheter is sufficient to reduce discomfort and minimize the risk of injury during the insertion process. Lubricating more than 2 inches may lead to excess lubrication, making it difficult to handle the catheter properly. Conversely, lubricating less than 1 inch may not provide enough lubrication to facilitate smooth insertion.

If the tip of the catheter accidentally comes in contact with the labia, it is important to prioritize patient safety and prevent the risk of infection. Getting a new catheter is the most appropriate action in this situation as it ensures that a clean and sterile catheter is used to minimize the risk of introducing bacteria into the urinary tract. Continuing with the same catheter may increase the risk of infection and compromise patient safety. Applying lubricant or checking for sterility may not address the potential contamination issue and therefore are not the best course of action.

After the delivery of the baby, the sudden gush of blood from the vagina indicates placental separation. During childbirth, the placenta detaches from the uterine wall and is expelled from the body. This separation can cause bleeding, which is why a sudden gush of blood is a sign of placental separation. The other options, such as operculum, rupture of membranes, and the second stage of labor, do not specifically relate to the expulsion of the placenta.

Gonadotrophin is a hormone that is produced during pregnancy. Its presence in the urine indicates that the person is pregnant. Therefore, advising the classmate to take a pregnancy test was the correct course of action and the positive result confirms the presence of gonadotrophin in her urine, confirming the pregnancy.

The presence of rusty brown urine suggests hematuria, which is the presence of red blood cells in the urine. This can be caused by various conditions such as urinary tract infections, kidney stones, bladder or kidney infections, or even certain medications. It is important to further investigate the cause of hematuria and determine the appropriate treatment for the patient.

Gonadotrophin is a hormone that is produced during pregnancy. Its presence in the urine indicates that the classmate is indeed pregnant. The other options, albumin, somatotrophin, and oxytocin, are not directly related to pregnancy. Therefore, the positive result of the pregnancy test suggests that the classmate is pregnant.

Based on the symptoms described, such as a firm, distended bladder that is displaced to one side of the midline, it suggests that the patient is experiencing urinary retention. Urinary retention occurs when the bladder is unable to empty properly, leading to a buildup of urine. This can be caused by various factors such as an obstruction in the urinary tract, nerve problems, or weakened bladder muscles.

When cleansing the urinary meatus, moving the swab downwards is the correct technique. This helps to prevent the spread of bacteria from the urethra towards the bladder. By moving the swab in a downward motion, any bacteria or contaminants are wiped away from the urethral opening, reducing the risk of infection.

The correct answer is to lubricate at least 2 inches of the tube. Lubrication is necessary to ease the insertion of the rectal tube and minimize discomfort for the patient. However, lubricating the entire tube is not necessary and may result in excess lubrication, which can be messy and uncomfortable for the patient. By lubricating at least 2 inches of the tube, it ensures that the portion of the tube that will be inserted into the rectum is adequately lubricated.

Dysuria refers to pain or discomfort during urination, while hesitancy refers to difficulty initiating the urine stream. Therefore, the patient's complaint of delay in urine stream and pain while voiding can be attributed to dysuria and hesitancy.

Saline solution is the safest solution to use in enema administration. Saline solution, also known as normal saline, is a sterile solution of sodium chloride in water. It is isotonic, meaning it has the same concentration of salts as the body's cells and fluids. This makes it safe to use and minimizes the risk of electrolyte imbalances or damage to the rectal lining. Oil, Fleet phosphate, and tap water can all have potential risks and side effects, such as irritation, dehydration, or electrolyte imbalances, making saline solution the safest choice.

The patient complained of pain while trying to inflate the balloon, which suggests that the catheter may not be properly placed. Aspirating the instilled fluid and advancing the catheter further can help ensure that the catheter is correctly positioned, reducing the discomfort for the patient.

The nurse will position the 5-year-old boy in a dorsal recumbent position to administer the enema solution. Dorsal recumbent position involves lying flat on the back with the knees bent and feet flat on the bed. This position allows for easy access to the rectal area and facilitates the administration of the enema. It is a comfortable and commonly used position for this procedure in pediatric patients.

The correct answer is the anterior fontanel. The anterior fontanel is a soft spot located between the parietal and frontal bones of a newborn's skull. It is a membrane-covered opening that allows for the growth and expansion of the skull during the early stages of development. The fontanel is palpable and can be used as a reference point for assessing the baby's hydration status and intracranial pressure. The suture lines refer to the junctions between the skull bones, while the cranium is the skull as a whole. The posterior fontanel is a different soft spot located at the back of the skull.

Maria's EDD (Estimated Due Date) can be calculated by adding 280 days (40 weeks) to her LMP (Last Menstrual Period) date. Therefore, her EDD would be January 27, 2010.

The main purpose of enema administration in a patient who is about to undergo laparotomy is to avoid accidental contamination of the abdominal contents. Laparotomy is a surgical procedure that involves opening the abdomen, and it is important to maintain a sterile environment to prevent infection. By administering an enema, the patient's bowels are emptied, reducing the risk of fecal matter contaminating the surgical site. This helps to ensure a safe and successful surgery.

After enema administration, it is recommended to encourage the patient to hold the solution for at least 5-10 minutes. This allows the solution to be effectively absorbed by the colon and increases the chances of successful treatment. Holding the solution for a longer period of time, such as an hour or 3 hours, may not provide any additional benefits and could potentially cause discomfort or unnecessary strain on the patient. Therefore, it is sufficient to hold the solution for 5-10 minutes to achieve the desired results.

The posterior fontanel is triangular in shape. Fontanels are soft spots on a baby's skull where the bones have not yet fully fused together. The posterior fontanel is located at the back of the head, towards the base of the skull. It is triangular in shape, with the apex pointing towards the front of the head. This fontanel allows for flexibility and growth of the skull during infancy.

Erythromycin eye ointment is the drug of choice for Crede's prophylaxis. Crede's prophylaxis is a preventive measure used to prevent neonatal conjunctivitis, which is an infection of the eye that can occur in newborns. Erythromycin is effective against the bacteria that commonly cause this infection, such as Chlamydia trachomatis and Neisseria gonorrhoeae. The ointment is applied to the newborn's eyes shortly after birth to prevent the transmission of these bacteria from the mother to the baby during delivery. This is why erythromycin eye ointment is the correct answer for Crede's prophylaxis.

The correct answer is three because during a high cleansing enema, it is recommended to change positions three times. The first position is lying on the left side, then the second position is lying on the back, and finally, the third position is lying on the right side. These position changes help to ensure that the enema solution reaches all areas of the colon and facilitates a thorough cleansing.

Mineral oil is the only option among the given choices that does not have any reported side effects when used as an enema solution. Soapsuds, saline, and tap water can all cause side effects such as irritation, electrolyte imbalance, or damage to the intestinal lining. However, mineral oil is a gentle lubricant that helps soften the stool and facilitate bowel movements without causing any known side effects.

After the cord is cleaned, applying a sterile cord clamp helps to prevent bleeding. This is because the cord clamp tightly secures the cord, cutting off the blood supply and preventing any further bleeding. It is a standard procedure to ensure that the baby does not lose excess blood and to promote proper healing of the cord stump.

Prior to performing Leopold's maneuver, it is important to instruct the client to void to avoid the escape of urine due to pressure on the abdomen. This is because Leopold's maneuver involves palpating the abdomen to assess the position of the fetus, and applying pressure on a full bladder can cause discomfort and potentially lead to the release of urine. By emptying the bladder before the procedure, the client can avoid this discomfort and potential embarrassment.

Enuresis is the involuntary passing of urine, which means that the person does not have control over when they urinate. In the case of Toby, a 3-year-old boy, experiencing nocturnal enuresis, it indicates that he is involuntarily passing urine during the night, which is considered abnormal for his age.

During the process of digital removal of fecal impaction, the nurse needs to periodically assess for both a change in pulse rate and blood pressure, as well as respiratory rate and temperature. This is important because the procedure can cause discomfort and stress on the patient's body, which may lead to changes in vital signs such as an increased heart rate or blood pressure. Additionally, monitoring the respiratory rate and temperature can help identify any potential complications or adverse reactions during the procedure.

The appropriate height of the enema can from the patient's anus is 12-18 inches. This is the recommended range for the height of the enema can to ensure proper flow and distribution of the enema solution. It allows for a sufficient amount of pressure to facilitate the flow without causing discomfort or injury to the patient.

Priming the enema tubing and rectal tube before introducing the solution helps to expel any air that may be present in the tubing. This is important because if air is introduced into the rectum, it can cause unnecessary distention and discomfort for the patient. Additionally, expelling air from the tubing helps to ensure that the enema solution is delivered properly and effectively. It does not promote asepsis or instill air into the rectum.

A straight catheter is used only during spot urine specimen collection or when measuring the residual urine. This type of catheter is designed for temporary use and is inserted into the bladder to drain urine directly. Unlike foley catheters, which are used for continuous drainage, straight catheters are used for specific purposes and are removed once the desired amount of urine has been collected or measured. Caude catheters and two-way foley catheters are not specifically designed for spot urine specimen collection or measuring residual urine.

The correct answer is that placing the patient in the left side lying position with the right leg acutely flexed facilitates the flow of solution to the colon. This position helps to promote gravity-assisted movement of the enema solution through the descending colon and into the sigmoid colon, which is located on the left side of the abdomen. This position allows for better distribution of the solution throughout the colon, aiding in the effectiveness of the enema.

The nurse would suction the mouth first to prevent aspiration. Aspiration occurs when secretions or foreign objects enter the lungs, which can lead to respiratory complications. Suctioning the mouth helps to remove any excess secretions that could potentially be aspirated into the lungs.

The baby's acrocyanosis indicates that there is slight bluish discoloration of the extremities, which is a normal finding in newborns. The apical pulse rate of 138 bpm is within the normal range for a newborn. The good vigorous cry indicates that the baby has a strong respiratory effort. The good muscle tone suggests that the baby has good muscle strength and is not floppy. The respiration rate of 40 cpm is also within the normal range. Based on these findings, the baby has a score of 9 on the APGAR scoring system, which indicates that the baby is in excellent condition at birth.

Premature closure of the fontanels is known as craniostenosis. The fontanels are the soft spots on a baby's skull that allow for growth and flexibility. When they close too early, it can lead to abnormal skull shape and potential developmental issues. Craniosystosis, craniumsystosis, and craniophlebitis are not the correct terms for this condition.

Prior to palpating the fundus of a pregnant client, it is important to wash and warm the hands. This is necessary to maintain proper hygiene and prevent the transmission of any potential pathogens to the client. Washing the hands helps to remove dirt, germs, and any other contaminants, while warming the hands helps to provide comfort to the client during the examination.

The correct answer is 5 ml. When inflating the retention balloon in an adult client, 5 ml of sterile water is used. This amount is sufficient to ensure proper inflation and secure placement of the catheter. Using too little water may result in inadequate inflation, while using too much water may cause discomfort or damage to the client's bladder. Therefore, 5 ml is the appropriate amount for inflating the retention balloon in an adult client.

Prior to performing an enema, it is important to place a rubber sheet on the client's bed. This is done to protect the bed linens and mattress from any potential leakage or spillage during the procedure. The rubber sheet acts as a waterproof barrier, preventing any fluids from seeping through and causing damage to the bed. It also helps in maintaining hygiene and cleanliness during the procedure.

The rectal route is used to check the infant's temperature because it is accurate and can also determine the presence of imperforate anus. The rectal route provides a more accurate measurement of body temperature compared to other routes, such as oral or axillary. Additionally, by using the rectal route, the nurse can also assess the presence of imperforate anus, a condition where the anus is not properly formed or is blocked. This information is important for the infant's overall health assessment and appropriate medical intervention if needed.

The correct answer is because this is the most developed muscle in the infant's body. The vastus lateralis muscle is one of the largest and most developed muscles in infants. It is located in the thigh and is commonly used for intramuscular injections in infants. This muscle provides a good amount of muscle mass and is less likely to cause discomfort or injury compared to other injection sites. Therefore, it is considered the most appropriate site for administering Vitamin K intramuscularly to infants.

A silicone catheter can be used for up to 2 months because silicone is a durable and long-lasting material that can withstand prolonged use without degrading or causing irritation. This makes it suitable for long-term catheterization in patients who require ongoing urinary drainage. Using a silicone catheter for a longer duration reduces the need for frequent catheter changes, minimizing discomfort and the risk of complications associated with catheter insertion.

Nocturnal frequency refers to the need to urinate frequently during the night. This is often associated with age because as people get older, their bladder capacity may decrease, leading to a need to empty the bladder more frequently. Age-related changes in the muscles that control bladder function can also contribute to nocturnal frequency. Stress, bladder habits, and work can also potentially contribute to nocturnal frequency, but age is the most commonly associated factor.

Taking a deep breath can help relax the internal anal sphincter. The internal anal sphincter is a smooth muscle that surrounds the anal canal and is responsible for involuntary control of bowel movements. Deep breathing activates the parasympathetic nervous system, which promotes relaxation and can help relax the muscles, including the internal anal sphincter. This can be beneficial during the insertion of a rectal tube, as it can help reduce discomfort and facilitate the procedure.

The fundic height is a measurement of the distance between the pubic bone and the top of the uterus. It is often used to estimate the gestational age of a fetus. In this case, Celine's fundic height is 32cm, which suggests a gestational age of 37 weeks and 7 days. This is because the fundic height typically corresponds to the number of weeks of pregnancy. Therefore, the correct answer is 37 weeks and 7 days.

The correct answer is Closed gravity drainage system. In a closed gravity drainage system, the urine bag is sealed to prevent any leakage or contamination. This system allows for the collection of urine by gravity, with the bag positioned lower than the patient's bladder. This ensures a smooth and continuous flow of urine without the risk of backflow or infection. Placing the urine bag in a closed gravity drainage system is the correct and appropriate method for managing urine collection.

The physician ordered a cleansing enema for the client, which requires the use of an isotonic solution. An isotonic solution has the same concentration of solutes as the body's cells, making it safe and compatible with the body. Normal saline solution, which is a solution of sodium chloride in water, is an example of an isotonic solution commonly used for enemas. Fleet phosphate, castor oil, and tap water are not isotonic solutions and may have different concentrations of solutes, making them unsuitable for this purpose.

The appropriate length of a rectal tube to be inserted into a 27-year-old client is 3-4 inches. This length is suitable for reaching the rectum and allowing for effective drainage or administration of medication. A shorter length may not reach the desired area, while a longer length may cause discomfort or injury to the client. Therefore, 3-4 inches is the correct choice for this situation.

Prior to catheterization, it is important to ensure proper hygiene to prevent infection. Antiseptic solution is commonly used to clean the perineal area before the procedure as it helps to kill or inhibit the growth of microorganisms. Feminine wash, normal saline solution, and sanitary solution may not have the same level of effectiveness in reducing the risk of infection.

The correct answer is Pawlick's grip. Leopold's maneuver is a series of four maneuvers used to determine the position of a fetus in the uterus. The third maneuver involves grasping the lower abdomen with both hands to assess the mobility and engagement of the fetal head. Pawlick's grip is another term used to refer to this maneuver. The other options, pelvic grip, Pavlick grip, and Paulick's grip, are not commonly used terms in relation to Leopold's maneuver.