A nurse is preparing to collect a blood specimen from a newborn via a heel stick. Identify the sequence of steps the nurse should follow. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
Confirm the newborn's identity.
Cleanse the site with an antiseptic.
Pierce the newborn's heel.
Apply gentle pressure to the site with dry gauze.
Warm the newborn's heel
The Correct Answer is A,E,B,C,D
Proper procedure for a heel stick includes:
A) Confirming the newborn's identity before any procedure. the nurse should confirm the newborn's identity by checking the identification band and asking the mother or caregiver to verify the name and date of birth.
E) The nurse should warm the newborn's heel by placing a warm compress or a heel warmer on the site for 3 to 5 minutes. This will increase blood flow and reduce pain.
B) Cleansing the site with an antiseptic to reduce the risk of infection. the nurse should cleanse the site with an antiseptic, such as alcohol or chlorhexidine, and let it air dry. The nurse should avoid using iodine, as it can interfere with some laboratory tests.
C) The nurse should pierce the newborn's heel with a sterile lancet, making sure to avoid the central area of the heel, where there are more nerves and bones. The nurse should use a single-use device that retracts automatically after use to prevent needlestick injuries.
D) The nurse should apply gentle pressure to the site with dry gauze to facilitate blood flow and collect the specimen in the appropriate container. The nurse should avoid squeezing or milking the site, as this can cause hemolysis or tissue damage.
E) The nurse should label the specimen with the newborn's name, date of birth, date and time of collection, and type of test. The nurse should also document the procedure in the newborn's chart, noting any difficulties or complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Incorrect- Abdominal breathing is a normal pattern in newborns and does not require immediate reporting.
B) Correct - Grunting is a sign of respiratory distress in a newborn and should be reported to the provider for further evaluation.
C) Incorrect- A respiratory rate of 55/min is within the normal range for a newborn and does not require immediate reporting.
D) Incorrect- Irregular respirations are common in newborns and may not necessarily be indicative of a problem.
Correct Answer is C
Explanation
A) Incorrect- Keeping the cord covered with a diaper is not recommended, as it can trap moisture and delay cord drying.
B) Incorrect- Cleaning the cord with antibacterial soap is not necessary and can actually interfere with the natural drying process.
C) Correct - Notifying the provider about odor coming from the cord is important, as it could indicate infection.
D) Incorrect- Some oozing of blood is normal as the cord stump dries, but bright red bleeding might be a sign of a problem and should be evaluated by a healthcare provider.
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