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 C

Explanation

A. Turn the newborn's head quickly to one side while they are sleeping: This action does not elicit the Moro reflex. The Moro reflex is a response to a sudden loss of support, not a head-turning motion.

B. Place a finger in the newborn's palm: This action would elicit the palmar grasp reflex, not the Moro reflex.

C. Clap hands after laying the newborn on a flat surface: The Moro reflex is triggered by a sudden, loud noise or movement, such as clapping hands. This response causes the newborn to extend and then quickly flex the arms, a characteristic sign of the reflex.

D. Hold the newborn upright with one foot touching the crib surface: This action is not related to the Moro reflex. The stepping reflex is elicited by holding the newborn upright with their feet touching a surface, not the Moro reflex.

A. Increase in calf size B. Capillary refill of 2 seconds C. Palpable cord-like vein D. Extremity feels cool to the touch

Correct Answer is C

Explanation

A. An increase in calf size can be a sign of deep-vein thrombosis (DVT), but it is not specific to
DVT and can occur with other conditions such as edema.
B. Capillary refill of 2 seconds is within the expected range and is not indicative of DVT.
C. A palpable cord-like vein is a classic sign of DVT and should be further assessed and reported for appropriate intervention.
D. An extremity feeling cool to the touch can be a sign of impaired circulation but is not specific to DVT and can occur with other vascular conditions.

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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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