The nurse is caring for a patient in labor and delivery. When near completing an assessment of the patient for dilatation and effacement, the electronic infusion device being used on the intravenous infusion alarms

Question

Which of these actions is most appropriate for the nurse to take? a. Complete the assessment, remove gloves, and silence the alarm.
b. Discontinue the assessment, and assess the intravenous infusion.
c. Complete the assessment, remove gloves, wash hands, and assess the intravenous infusion.
d. Discontinue the assessment, remove gloves, use hand gel, and assess the intravenous infusion.

Answer 1

C
Medical asepsis or clean technique includes procedures to decrease the number of organisms present and to prevent the transfer of organisms. Wearing gloves while assessing the dilatation and effacement of a labor and delivery patient, removing gloves, washing hands after contact with body fluids, and then assessing the intravenous infusion will assist in the prevention and transfer of any potential organisms to this intravenous line. Completing the assessment, removing gloves, and silencing the alarm leaves out the crucial step of decontaminating and washing the hands. Discontinuing the assessment and assessing the IV leaves out removing the gloves and decontamination, as well as completing the assessment for the patient. Discontinuing the assessment, removing gloves, using hand gel, and assessing the IV is incorrect because upon exposure to body fluids, washing hands is appropriate.