A nurse is assisting in the care of a client who is in labor and whose membranes ruptured 6 hr ago. Which of the following is an appropriate nursing intervention for this client?

A) Correct - Keeping the car seat rear-facing is recommended until your baby reaches the age of 2 or the weight and height limits specified by the car seat manufacturer. This is to provide maximum protection to the baby's developing head and neck.
B) Incorrect- Placing the shoulder harness at the level of the baby's shoulders is important, but the rear-facing position is a higher priority.
C) Incorrect- The retainer clip should be positioned at the level of the baby's armpits to ensure proper placement of the harness straps.
D) Incorrect- The angle of recline is important to prevent the baby's head from flopping forward, but the rear-facing position itself is more crucial.

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.