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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Constipation is not a common or serious adverse effect of cefazolin and typically does not require provider notification.

B. Elevated skin patches may indicate an allergic reaction or a more severe hypersensitivity response, such as a rash or urticaria. This requires prompt reporting to the provider to prevent progression to more serious reactions like anaphylaxis.

C. Ringing in the ears (tinnitus) is associated with ototoxic medications, not cefazolin, and is not a typical adverse effect of this antibiotic.

D. Depression is not linked to cefazolin use and is not a side effect the adolescent needs to monitor in this context.

A. A client who has a head injury and whose pupils are fixed and dilated B. A client who has a dislocated shoulder and reports a pain level of 8 on a scale from 0 to 10 C. A client who has a 20.3-cm (8-in) scalp laceration with intermittent bleeding D. A client who has diminished breath sounds and paradoxical chest movement

Correct Answer is D

Explanation

A client who has a head injury and whose pupils are fixed and dilated: This client likely has a severe head injury with signs of increased intracranial pressure, which requires urgent intervention. However, airway and breathing take precedence over neurological status in triage. B. A client who has a dislocated shoulder and reports a pain level of 8 on a scale from 0 to 10: While this client is in pain, dislocated shoulder is not immediately life-threatening in the context of a mass casualty situation.
C. A client who has a 20.3-cm (8-in) scalp laceration with intermittent bleeding: Although this client has a significant laceration, it is not immediately life-threatening compared to compromised breathing.
D. A client who has diminished breath sounds and paradoxical chest movement: This client is likely experiencing a tension pneumothorax, a life-threatening condition that requires immediate intervention to decompress the chest and restore normal breathing.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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