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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?

A.

Cool the newborn's heel prior to the procedure.

B.

Puncture the center of the newborn's heel.

C.

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

D.

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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Related Questions

Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"A"},"C":{"answers":"A"}}

Explanation

Preterm Labor

Preterm labor refers to labor that begins before 37 weeks of gestation. The key findings associated with preterm labor are:

  • Cervical effacement and dilation: The client is 100% effaced and 2 cm dilated.
  • Regular uterine contractions: The client is experiencing contractions every 3 minutes, lasting 60 seconds.
  • Bloody show: The presence of bloody mucus discharge is another sign of preterm labor.
  • Low backache: The client reports cramping and low back pain.

Preterm Prelabor Rupture of Membranes (PPROM)

PPROM refers to the rupture of membranes before labor begins and before 37 weeks of gestation. The key findings associated with PPROM are:

  • Vaginal discharge: The client reported urinary leakage earlier, which could be misinterpreted as amniotic fluid leakage. Clear mucus discharge can also be a sign of ruptured membranes.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"B"},"G":{"answers":"A"}}

Explanation

  1. Administration of IV fluids: This is anticipated as it ensures the client remains well-hydrated, which is important for both maternal and fetal health.
  2. Continuous monitoring of FHR: This is anticipated to monitor the fetal well-being and ensure there are no signs of fetal distress.
  3. Abdominal ultrasound: This is anticipated to assess fetal growth, amniotic fluid levels, and placental positioning.
  4. Digital cervical exam to assess dilation and effacement: This is contraindicated because frequent cervical exams can increase the risk of infection and may cause unnecessary discomfort, especially if there are no signs of labor.
  5. Laboratory testing: CBC, Blood Type & Rh, Coagulation Studies: These tests are anticipated to provide important information about the client's blood count, blood type, Rh status, and coagulation parameters, which are crucial for managing potential complications.
  6. Placement of an internal fetal spiral electrode: This is contraindicated as it is an invasive procedure that carries risks, and it is unnecessary given that the FHR is within normal limits with external monitoring.
  7. Administration of betamethasone: This is anticipated as betamethasone is often given to promote fetal lung maturity in cases where there is a risk of preterm birth.

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