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 A

Explanation

A. Fatigue is a common symptom of anemia, which can result from a low hemoglobin level.
Decreased oxygen-carrying capacity leads to feelings of tiredness.
B. Thickened fingernails are not typically associated with low hemoglobin levels. This symptom is more commonly seen in conditions such as fungal infections or psoriasis.
C. The need to go to the bathroom frequently is not directly related to low hemoglobin levels. It may be indicative of other conditions such as urinary tract infections or diabetes.
D. Shaky hands are not typically associated with low hemoglobin levels. This symptom may be seen in conditions such as essential tremor or Parkinson's disease.

A. Administer bupropion 1 hr before meals. B. Allow the client access to food throughout the day. C. Weigh the client once weekly. D. Observe the client for 1 hr after meals.

Correct Answer is D

Explanation

A. Incorrect. Bupropion is not typically used as a first-line treatment for bulimia nervosa. Additionally, administering it before meals is not a standard practice for managing bulimia nervosa.
B. Incorrect. Allowing the client unrestricted access to food throughout the day may exacerbate binge-eating behaviors associated with bulimia nervosa. Structured meal plans are typically recommended instead.
C. Incorrect. While monitoring weight is important in the management of bulimia nervosa, weighing the client once weekly may not provide adequate monitoring, as fluctuations in weight can occur more frequently.
D. Correct. Observing the client for a period after meals helps to prevent purging behaviors, such as self-induced vomiting or misuse of laxatives, which are common in bulimia nervosa. This intervention allows for immediate intervention if purging behaviors are observed and can help ensure the client's safety.

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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?

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Naxlex Comprehensive Predictor Exams

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