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 minutes prior to the procedure.
Elevate the newborn's foot for 15 minutes following the procedure.
The Correct Answer is C
The nurse should apply a heat pack 5 to 10 minutes prior to the procedure when planning to obtain blood from a newborn via a heel stick. This helps to increase blood flow to the area and makes it easier to obtain the specimen.
a) Puncturing the heel to a depth of 4 mm is too deep and can cause injury to the newborn. The recommended depth for a heel stick is 2.4 mm or less.
b) Withholding feeding prior to collecting the specimen is not necessary.
d) Elevating the newborn's foot for 15 minutes following the procedure is not necessary.
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Correct Answer is A
Explanation
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Demonstrating how to use an incentive spirometer requires specialized knowledge and the ability to provide clear instructions. It is typically within the scope of practice of licensed healthcare professionals, such as nurses or respiratory therapists, who have the necessary expertise to properly educate and guide patients in using an incentive spirometer. This task should not be delegated to an AP.
Measuring and assessing the depth of a pressure injury requires clinical judgment and accurate evaluation, which falls within the scope of practice of a licensed nurse. It involves understanding wound assessment, proper technique for measuring depth, and interpreting the findings. This task should be performed by the nurse rather than an AP.
Changing the appliance on a new colostomy involves skills such as assessing the stoma, selecting the appropriate appliance, and ensuring proper application. This task requires specialized knowledge and training in stoma care, and it should be performed by a licensed nurse who has the expertise in managing ostomies. It should not be delegated to an AP.
Correct Answer is D
Explanation
Neisseria gonorrhoeae is the bacterium responsible for the sexually transmitted infection known as gonorrhea. Gonorrhea is a reportable communicable disease, meaning healthcare providers are required to report cases to the appropriate public health authorities. This allows for tracking and monitoring of the disease, implementation of appropriate public health measures, and prevention of further spread of the infection.
Sarcoptes scabiei: This refers to scabies, a parasitic infestation caused by mites. While scabies can be contagious, it is not typically a reportable disease to the state health department.
Impetigo contagiosa: Impetigo is a bacterial skin infection that can be caused by various bacteria, including Staphylococcus aureus and Streptococcus pyogenes. Although it is contagious, it is not typically a reportable disease to the state health department.
Human papillomavirus (HPV): HPV is a viral infection transmitted through sexual contact. While it is a significant public health concern due to its association with cervical cancer and other conditions, it is not usually a reportable disease to the state health department. However, certain states may have specific reporting requirements for HPV-related diseases or conditions, such as cervical cancer. It is important to be familiar with the specific reporting guidelines of the state in question.
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