A nurse is planning to obtain a blood specimen from a newborn via a heel stick.
Which of the following actions should the nurse take?

Cool the newborn's heel prior to the procedure.

Puncture the center of the newborn's heel.

Cleanse the puncture site with alcohol gauze prior to the procedure.

Administer vitamin K 30 minutes prior to each blood draw.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Cooling the newborn’s heel would constrict blood vessels and make it more difficult to obtain a blood sample. Warming the heel is the preferred method to increase blood flow.

Choice B rationale

Puncturing the center of the newborn’s heel is not recommended as it could cause more pain and potential injury to the bone. The puncture should be done on the outer edges of the heel.

Choice C rationale

Cleansing the puncture site with alcohol gauze is essential to reduce the risk of infection and ensure that the sample is not contaminated.

Choice D rationale

Administering vitamin K before each blood draw is unnecessary. Vitamin K is typically given as a one-time dose to prevent bleeding issues, not related to blood draw procedures.

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Correct Answer is B

Explanation

Choice A rationale

Variable decelerations are associated with umbilical cord compression, not placenta previa. In placenta previa, the placenta covers the cervical os, but it does not typically cause variable decelerations on fetal monitoring.

Choice B rationale

Painless vaginal bleeding is a hallmark sign of placenta previa. This occurs because the placenta is located near or over the cervical os, leading to bleeding when the cervix dilates or effaces.

Choice C rationale

A rigid abdomen is more indicative of placental abruption, where the placenta detaches prematurely from the uterine wall, causing pain and a tense abdomen, not typically seen in placenta previa.

Choice D rationale

Uterine tachysystole is characterized by excessive uterine contractions and is not a clinical finding related to placenta previa. Tachysystole often results from excessive oxytocin use or other uterine stimulants.

A. Meconium stools. B. Depressed fontanels. C. Rust-stained urine. D. Overlapping suture lines.

Correct Answer is B

Explanation

Choice A rationale

Meconium stools are common in newborns and not a concern in the context of weight loss.

Choice B rationale

Depressed fontanels can indicate dehydration in a newborn, which is critical, especially with significant weight loss.

Choice C rationale

Rust-stained urine is often due to urate crystals and is typical in newborns, not specifically alarming.

Choice D rationale

Overlapping suture lines can be a normal finding in a newborn's head and not indicative of an acute problem relating to weight loss.

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A nurse is planning to obtain a blood specimen from a newborn via a heel stick.Which of the following actions should the nurse take?

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A nurse is planning to obtain a blood specimen from a newborn via a heel stick.
Which of the following actions should the nurse take?