A nurse is assessing a 4-month-old infant during a well-baby visit.
For which of the following findings should the nurse notify the provider?

The correct answer is Choice A.

Choice A rationale

Ensuring that all patients are moved out of harm’s way is the first priority in a nursing home fire situation. This action aligns with the principles of the ABCs of nursing prioritization, where ensuring safety and preventing harm is paramount.

Choice B rationale

Removing all flammable materials from the area and extinguishing the fire is important, but it comes after ensuring the safety of the patients. The primary focus should be on patient safety.

Choice C rationale

Reporting to the area of the fire and taking measures to extinguish and/or contain it, if possible, is a secondary action. The immediate priority is to ensure the safety of the patients.

Choice D rationale

Evacuating all patients from the building immediately is not always feasible or safe. The priority is to move patients out of immediate harm’s way and then proceed with further evacuation if necessary.

The correct answer is Choice B.

Choice A rationale

Applying a cool pack to the heel prior to the procedure is not recommended as it can constrict blood vessels and make it more difficult to obtain a blood sample.

Choice B rationale

Puncturing the outer aspect of the heel is the correct technique for collecting a capillary blood specimen from an infant. This area has fewer nerve endings and is less likely to cause pain or injury.

Choice C rationale

Using a surgical blade to obtain the specimen is not appropriate for a capillary blood draw. A lancet should be used instead to make a small puncture in the skin.

Choice D rationale

Wiping the site with alcohol after the puncture is not recommended as it can cause irritation and discomfort. The site should be cleaned with alcohol before the puncture and then covered with a sterile gauze pad after the procedure. .