A nurse is preparing to collect a blood specimen from a newborn via heelstick. Which of the following actions should the nurse take? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
Place a heel warmer on the newborn's heel.
Confirm the identity of the newborn.
Apply pressure to the puncture site with a dry gauze pad.
Label the specimen per facility protocol.
Clean the puncture site with an antiseptic cleanser.
The Correct Answer is B, A, E, C, D
This sequence ensures proper identification, infection control, specimen collection, and safety for the newborn.
Choice A rationale:
The nurse should place a heel warmer on the newborn's heel for 3 to 5 minutes before the heelstick to increase blood flow and facilitate collection.
Choice B rationale:
The nurse should confirm the identity of the newborn before collecting any specimen to ensure patient safety and avoid errors.
Choice C rationale:
The nurse should apply pressure to the puncture site with a dry gauze pad to stop bleeding and promote clotting.
Choice D rationale:
The nurse should label the specimen per facility protocol to ensure accurate identification and processing.
Choice E rationale:
The nurse should clean the puncture site with an antiseptic cleanser to prevent infection and reduce contamination of the specimen.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
A blood pressure of 78/60 mm Hg is indicative of hypotension which is a common complication of anorexia nervosa. However. the low body temperature takes precedence
Choice B rationale:
Weight loss of 20% over the last 6 months is concerning but may not be an immediate indicator for acute care admission.
Choice C rationale:
An apical pulse rate of 50/min is bradycardia, which can be a result of anorexia nervosa, but it may not be an immediate indicator for acute care admission unless the client is symptomatic.
Choice D rationale:
A body temperature of 35.5°C (95.9°F) is below a normal range signfyng hypothermia which needs immedate intervention.
Correct Answer is A
Explanation
Choice A rationale:
Clients with obsessive-compulsive disorder (OCD) often benefit from maintaining control over their daily activities and schedules. Allowing the client autonomy in scheduling activities can help them manage their symptoms while feeling in control.
Choice B rationale:
Antipsychotic medications are not the first-line treatment for OCD, and their use would depend on the presence of other coexisting conditions.
Choice C rationale:
Providing ample time for rituals may inadvertently reinforce the compulsive behaviors associated with OCD. Cognitive-behavioral therapy (CBT) with exposure and response prevention is the recommended treatment for OCD.
Choice D rationale:
Implosion therapy, also known as flooding, exposes the client to anxiety-provoking stimuli in a controlled and safe environment. However, it is not typically the first-line treatment for OCD and requires careful implementation under the guidance of a mental health professional.
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