A nurse is preparing to obtain a blood sample from a newborn’s heel. In what order should the nurse perform the procedure?

Clean the area with an antiseptic

Apply a warm cloth to the newborn’s heel for 5 to 10 minutes

Puncture the outer aspect of the newborn’s heel

Collect the blood specimen

Apply pressure to the site with a dry gauze pad

Answer and Explanation

The Correct Answer is B, A, C, D, E

Step 1 is to apply a warm cloth to the newborn’s heel for 5 to 10 minutes. Warming the heel improves blood flow to the area, making it easier to obtain a blood sample.

Step 2 is to clean the area with an antiseptic. This is to prevent infection.

Step 3 is to puncture the outer aspect of the newborn’s heel. The outer aspect of the heel is less sensitive and less likely to be injured by the lancet.

Step 4 is to collect the blood specimen. After the heel has been punctured, blood will start to flow out and can be collected.

Step 5 is to apply pressure to the site with a dry gauze pad. This is to stop the bleeding after the blood sample has been collected.

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Correct Answer is ["A","B","F"]

Explanation

Choice A rationale
Maintaining a low-stimulation environment is recommended for newborns exhibiting clinical findings of NAS56. This can help to reduce symptoms such as irritability and restlessness.
Choice B rationale
Weighing the newborn daily is important in the care of a newborn with NAS56. This can help to monitor the newborn’s growth and development, and any significant changes in weight could indicate a need for further medical intervention.
Choice C rationale
Advising the parent to avoid breastfeeding is not typically recommended for mothers who used opioids prior to pregnancy and were prescribed methadone during pregnancy. In fact, breastfeeding is often encouraged for these mothers, as it can help to reduce the severity of NAS symptoms in the newborn.
Choice D rationale
Avoiding eye contact with the newborn during feeding is not typically recommended as part of the care for a newborn with NAS56. Eye contact can help to promote bonding between the parent and the newborn.
Choice E rationale
The administration of naloxone is not typically recommended for a newborn with NAS56. Naloxone is a medication used to reverse the effects of opioids, but it is not typically used in the treatment of NAS56.
Choice F rationale
Swaddling the newborn with flexed extremities can help to comfort a newborn with NAS56. This can help to reduce symptoms such as irritability and restlessness.
Choice G rationale
This option is not typically necessary for the management of neonatal abstinence syndrome (NAS). The Ballard score is used to assess gestational age and physical maturity of a newborn, but it is not a routine part of monitoring for NAS.

A. Assist the client in pulling their knees toward their abdomen. B. Press firmly on the client’s suprapubic area. C. Apply pressure to the client’s fundus. D. Move the client onto their hands and knees.

Correct Answer is A

Explanation

In the event of shoulder dystocia during the second stage of labor, the provider may instruct the nurse to perform the McRoberts maneuver. This involves assisting the client in pulling their knees toward their abdomen. This position effectively flattens the sacrum, changes the angle of the pelvic inlet, and allows more room for the baby to pass through the birth canal.

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A nurse is preparing to obtain a blood sample from a newborn’s heel. In what order should the nurse perform the procedure?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","B","F"]

Explanation

A nurse is caring for a client who is in the second stage of labor and is experiencing shoulder dystocia. The provider instructs the nurse to perform the McRoberts maneuver. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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