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 minutes prior to the procedure.
Elevate the newborn's foot for 15 minutes following the procedure.
The Correct Answer is C
The nurse should apply a heat pack 5 to 10 minutes prior to the procedure when planning to obtain blood from a newborn via a heel stick. This helps to increase blood flow to the area and makes it easier to obtain the specimen.
a) Puncturing the heel to a depth of 4 mm is too deep and can cause injury to the newborn. The recommended depth for a heel stick is 2.4 mm or less.
b) Withholding feeding prior to collecting the specimen is not necessary.
d) Elevating the newborn's foot for 15 minutes following the procedure is not necessary.
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Related Questions
Correct Answer is B
Explanation
b. Seizure pads
Explanation:
The nurse should place seizure pads in the client's room when admitting a client with bacterial meningitis. Bacterial meningitis is an infection that affects the meninges, the protective membranes covering the brain and spinal cord. It can cause inflammation and swelling of the brain, leading to an increased risk of seizures.
Seizure pads are specifically designed to provide a cushioning and protective barrier between the client's head and the hard surface, reducing the risk of injury during a seizure. They are placed on the bed or matress to help prevent head trauma or other injuries that may occur if a seizure occurs.
Now, let's discuss why the other options are not necessary for the client with bacterial meningitis:
a. Oral irrigating device:
An oral irrigating device is not necessary for a client with bacterial meningitis. Bacterial meningitis primarily affects the central nervous system and does not require oral care interventions. The focus of care for these clients is on managing the infection, monitoring vital signs, and providing supportive care.
c. Sterile gloves:
While sterile gloves are commonly used in healthcare settings, they are not specifically required for the care of a client with bacterial meningitis. Standard precautions, including the use of non-sterile gloves, are sufficient for providing care to these clients. Sterile gloves are typically used for invasive procedures or when there is a need to maintain a sterile field.
d. Tongue blade:
A tongue blade is not necessary for the care of a client with bacterial meningitis. Tongue blades are typically used for oral assessments or when examining the throat, which are not directly related to the management or treatment of bacterial meningitis. The focus of care for these clients is on infection control, monitoring for complications, and providing comfort and support.
In summary, when admitting a client with bacterial meningitis, the nurse should prioritize placing seizure pads in the client's room to ensure their safety during potential seizure activity.

Correct Answer is A
Explanation
The nurse should allow the family as much time as they want with the client who has just died. This promotes comfort for the family and allows them to say goodbye to their loved one.
a) Using paper tape to hold the client's eyelids open is not appropriate and can be distressing for the family.
b) Placing the client in a supine position is not necessary and may not be comfortable for the client.
c) Avoiding repeating information about the client's death is not helpful. The nurse should provide clear and honest information to the family and answer any questions they may have.
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