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

The nurse should include the instruction to "verify the identity of anyone who wants to remove your baby from the room" in the teaching about security procedures. It is important for parents to be vigilant and ensure that only authorized personnel have access to their baby.

Option b is incorrect because it may not be safe for the parent to leave their baby unattended in their room while they walk in the hallway.

Option c is incorrect because newborns typically have two identification bands, one on their arm and one on their leg.

Option d is incorrect because parents should not leave the unit with their baby without proper authorization and discharge procedures.

A. Flexes the client's aﬀected hip to 120 B. Adducts the client's aﬀected leg C. Checks the neurovascular status of the client's lower extremities every 6 hr D. Applies a sequential compression device to the client's lower extremities

Correct Answer is D

No explanation

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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