A nurse is planning to obtain blood from a newborn via a heel stick. Which of the following actions should the nurse take?
Puncture the heel to a depth of 4 mm to obtain the specimen.
Withhold feeding prior to collecting the specimen.
Apply a heat pack 5 to 10 min prior to the procedure.
Elevate the newborn's foot for 15 min following the procedure.
The Correct Answer is C
Choice A Rationale: Puncturing the heel to a depth of 4 mm may be too deep and could cause injury to the newborn's foot. The recommended depth is usually less than 2 mm to avoid damaging underlying bone or tissues.
Choice B Rationale: Withholding feeding prior to collecting the specimen is not necessary and could cause unnecessary distress to the newborn. Feeding can help in soothing the infant and may even improve blood flow for the procedure.
Choice C Rationale: Applying a heat pack 5 to 10 minutes prior to the procedure is recommended as it helps to increase blood flow to the area, making the collection easier and potentially less painful for the newborn.
Choice D Rationale: Elevating the newborn's foot for 15 minutes following the procedure is not a standard recommendation. Post-procedure care typically involves applying gentle pressure to stop bleeding and then covering the puncture site with a bandage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Instruct the client to report the theft to the police: While reporting theft to the police may be necessary, the immediate concern is the safety and well-being of the client, especially if financial exploitation or abuse is suspected.
B. Report the possible abuse to adult protective services: Suspected financial exploitation or abuse of an older adult should be reported to the appropriate authorities, such as adult protective services, for investigation and intervention.
C. Ask the client if there is another family member they can call for financial help: While involving other family members may be appropriate in some situations, suspected abuse or exploitation requires intervention from trained professionals.
D. Restrict visitation for the client's family until discharge: Restricting visitation should only be done if there is a clear risk to the client's safety, and it should not be the first action taken in response to suspected abuse.
Correct Answer is D
Explanation
A. Incorrect. Pinching the infant's nares can cause distress and may not effectively prevent aspiration.
B. Incorrect. Administering the whole dose at once increases the risk of the infant choking or aspirating the medication.
C. Incorrect. Holding the infant in a side-lying position may not effectively prevent aspiration and may increase the risk of choking.
D. Correct. Administering the medication using a needleless syringe in the buccal cavity allows for slow and controlled administration, reducing the risk of aspiration. This method also minimizes the chance of the infant gagging or spitting out the medication.
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