A nurse is caring for a newborn who requires a blood glucose test. Which of the following actions should the nurse take?

Apply a warm pack to the puncture site prior to the procedure.

Apply a mummy restraint to the newborn for the procedure.

Apply antiseptic solution to the puncture site after the procedure.

Elevate the extremity prior to the procedure.

Answer and Explanation

The Correct Answer is A

A. Applying a warm pack to the puncture site before the procedure increases blood flow to the area, which makes the blood sample collection easier and reduces discomfort for the newborn.

B. A mummy restraint may not be necessary for a routine blood glucose test. The nurse can gently hold the newborn in place during the procedure without needing to fully restrain them.

C. Antiseptic solution is typically applied before the puncture to cleanse the area. After the procedure, gentle pressure and bandaging are more appropriate to stop bleeding.

D. Elevating the extremity is unnecessary for a newborn blood glucose test, as warming the area is more effective in promoting blood flow to the puncture site.

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Correct Answer is D

Explanation

A. a positive Moro reflex, is a normal and expected finding in a newborn. It is not a cause for concern.
B. erythema toxicum, is a benign rash that is common in newborns and does not require reporting to the provider.
C. acrocyanosis, is a normal finding in newborns and is not typically a cause for concern.
D. an elevated bilirubin level, can indicate jaundice, which may require treatment or further evaluation. This finding should be reported to the provider for appropriate management.

A. Administer the medication into the deltoid muscle. B. Check the mother's Rh factor prior to administration. C. Administer the medication 12 hr after birth. D. Administer the medication with a 25 gauge needle.

Correct Answer is D

Explanation

A: Administering the medication into the deltoid muscle is not recommended for newborns due to their underdeveloped muscle mass and the potential for injury. The vastus lateralis muscle in the thigh is the preferred site for intramuscular injections in infants.

B: Checking the mother's Rh factor is not directly related to the administration of phytonadione, which is given to prevent vitamin K deficiency bleeding in the newborn, a condition unrelated to the mother's Rh factor.

C: Administering the medication 12 hours after birth is not the standard practice. Phytonadione is typically given within the first hour after birth to ensure prompt prevention of hemorrhagic disease of the newborn.

D: Administering the medication with a 25 gauge needle is appropriate as it is small enough to cause minimal discomfort and large enough to ensure proper delivery of the medication into the infant's muscle tissue.

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A nurse is caring for a newborn who requires a blood glucose test. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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