A nurse is performing a skin assessment on a client who has dark skin.

Which of the following locations on the client’s body should the nurse observe to assess for cyanosis?

The correct answer is choice D. Minimize noise in the newborn’s environment.

This is because neonatal abstinence syndrome (NAS) is a condition that affects newborns who are exposed to opioids or other addictive substances in the womb. These substances can cause withdrawal symptoms in the newborns, such as excessive crying, tremors, vomiting, diarrhea, and seizures.

Minimizing noise and other stimuli can help calm the newborn and reduce stress.

Choice A is wrong because swaddling the newborn with his legs extended can increase muscle tension and discomfort. Swaddling should be done with the legs flexed and hips abducted to prevent hip dysplasia.

Choice B is wrong because administering naloxone to the newborn can cause severe withdrawal symptoms and respiratory depression. Naloxone is an opioid antagonist that reverses the effects of opioids, but it is not recommended for newborns with NAS unless they have life-threatening respiratory depression.

Choice C is wrong because maintaining eye contact with the newborn during feedings can overstimulate the newborn and cause agitation. Eye contact should be avoided or limited during feedings for newborns with NAS.

Choice A reason

Setting the IV infusion pump to administer the blood over 6 hours is not the recommended rate for administering packed RBCs. Blood transfusions are typically given more rapidly, usually within 2 to 4 hours. The specific rate may vary depending on the client's condition and the provider's order.

Choice B reason

Administering the blood via a 21-gauge IV needle is not typically related to the administration of the packed RBCs. The appropriate gauge of the IV needle for blood transfusions depends on the client's condition and the type of transfusion. Larger-gauge needles are often used for blood transfusions to allow for a faster flow rate and prevent haemolysis of the blood cells.

Choice C reason

Checking the client's vital signs from the previous shift prior to the initiation of the transfusion is not sufficient for ensuring the client's safety during the blood transfusion. The nurse should assess the client's current vital signs, including temperature, heart rate, blood pressure, and respiratory rate, before initiating the transfusion. Monitoring vital signs is essential during the transfusion to detect any adverse reactions or changes in the client's condition.

Choice D reason

Rush the blood administration tubing with 0.9% sodium chloride prior to the transfusion is the correct answer. When preparing to administer a blood transfusion to an adult client with chronic anaemia, the nurse should rush the blood administration tubing with 0.9% sodium chloride (normal saline) prior to the transfusion. This process is called priming the tubing.

Priming the tubing helps remove any residual air from the tubing and ensures that the blood transfusion is administered smoothly without introducing air into the client's bloodstream. Air embolisms can be a serious complication, and priming the tubing with normal saline helps prevent this risk.