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.

Answer and Explanation

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

a. Giving broad openings

The nurse is using the therapeutic technique of giving broad openings. This technique encourages the client to freely express themselves and choose the focus of the conversation. By asking, "What has been happening with you today?" the nurse is inviting the client to share their thoughts, feelings, and experiences without imposing any specific topic or direction.

Explanation for the other options:

b. Focusing: Focusing is a therapeutic technique where the nurse directs the conversation to a specific topic or issue. In this scenario, the nurse is not guiding the client's response toward a particular area of discussion.

c. Reﬂecting: Reﬂecting is a therapeutic technique where the nurse repeats or paraphrases the client's words or feelings to demonstrate understanding and encourage further exploration. The nurse's statement in this scenario does not involve reﬂecting the client's words or feelings.

d. Seeking clarification: Seeking clarification is a therapeutic technique used to obtain more specific information or clear up any confusion. The nurse's statement in this scenario does not involve seeking clarification from the client.

In summary, by using a broad opening, the nurse allows the client to choose the focus of the conversation

and encourages them to share their experiences and concerns.

A. "I should keep my baby rear-facing in the car seat until she is 2 years old." B. "I should place my baby in the car seat at a 90-degree angle." C. "I should position the car seat's retainer clip at the level of my baby's belly button." D. "I should enable the airbag when my baby is in the front seat of the car."

Correct Answer is A

Explanation

Keeping a baby rear-facing in the car seat until they reach the age of 2 years old or until they reach the maximum height and weight limits recommended by the car seat manufacturer is a crucial safety guideline. Rear-facing car seats provide better support for a baby's head, neck, and spine in the event of a crash, reducing the risk of severe injuries.

"I should place my baby in the car seat at a 90-degree angle." The correct positioning for a rear-facing car seat is typically between a 30 to 45-degree angle. This angle helps ensure the baby's airway remains open and prevents their head from flopping forward.

"I should position the car seat's retainer clip at the level of my baby's belly button." The retainer clip of the car seat should be positioned at armpit level, not at the level of the baby's belly button. The retainer clip is designed to secure the harness straps and should be placed across the chest, resting on the bony part of the shoulders.

"I should enable the airbag when my baby is in the front seat of the car." It is not safe to have a rear-facing car seat with a baby in the front seat of a vehicle with an active airbag. Airbags can pose a significant risk to infants due to the force with which they deploy. It is recommended to place a rear-facing car seat in the back seat of the vehicle and disable the airbag in the front passenger seat if the baby needs to ride in the front.

It is important for parents to receive proper education on car seat safety and follow the guidelines set forth by car seat manufacturers, national recommendations, and local laws and regulations.

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A nurse is planning to obtain blood from a newborn via a heel stick. Which of the following actions should the nurse take?

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