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 min prior to the procedure.
Elevate the newborn's foot for 15 min following the procedure.
The Correct Answer is C
Choice A Rationale: Puncturing the heel to a depth of 4 mm may be too deep and could cause injury to the newborn's foot. The recommended depth is usually less than 2 mm to avoid damaging underlying bone or tissues.
Choice B Rationale: Withholding feeding prior to collecting the specimen is not necessary and could cause unnecessary distress to the newborn. Feeding can help in soothing the infant and may even improve blood flow for the procedure.
Choice C Rationale: Applying a heat pack 5 to 10 minutes prior to the procedure is recommended as it helps to increase blood flow to the area, making the collection easier and potentially less painful for the newborn.
Choice D Rationale: Elevating the newborn's foot for 15 minutes following the procedure is not a standard recommendation. Post-procedure care typically involves applying gentle pressure to stop bleeding and then covering the puncture site with a bandage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Nitrites negative is a normal finding and does not typically require notification of the provider. Nitrites are usually present in the urine when there is a urinary tract infection.
B. Ketones positive in the urine can indicate diabetic ketoacidosis (DKA), which is a serious condition requiring prompt medical attention. Therefore, the nurse should notify the provider about this result.
C. Uric acid levels can be elevated in conditions such as gout or kidney disease, but the specific value provided is within the normal reference range for a 24-hour urine collection. Therefore, it does not warrant immediate notification.
D. Specific gravity of 1.020 is within the normal range (typically 1.005 to 1.030) and does not usually require notification of the provider.
Correct Answer is C
Explanation
A. Vitamin C: While a vegan diet may limit sources of vitamin C, it is typically abundant in fruits and vegetables, so deficiency is less likely.
B. Potassium: Potassium deficiency is not typically associated with a vegan diet, as plant-based foods such as fruits, vegetables, legumes, and nuts are good sources of potassium.
C. Vitamin D: Vitamin D is primarily found in animal products, so individuals following a vegan diet may be at risk of deficiency unless they consume fortified foods or supplements.
D. Magnesium: While magnesium deficiency can occur in anyone with an inadequate intake of magnesium-rich foods, it's not necessarily more common in vegans compared to omnivores.
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