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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Related Questions
Correct Answer is B
Explanation
The charge nurse should explain to the assistive personnel (AP) that one of the responsibilities of a licensed practical nurse (LPN) is providing direct client care. LPNs work under the supervision of registered nurses (RNs) and are trained to deliver basic nursing care to clients. This includes tasks such as administering medications, monitoring vital signs, dressing wounds, assisting with activities of daily living (ADLs), and reporting any changes in the client's condition to the RN.
The other options are not typically within the scope of practice for an LPN:
a. Coordinating client care: The coordination of client care is primarily the responsibility of the RN. While LPNs may contribute to the coordination of care by providing input and collaborating with the healthcare team, the overall coordination is usually managed by the RN.
c. Assessing a client's health status: Assessing a client's health status is a role primarily performed by RNs. LPNs may gather data and contribute to the assessment process, but the comprehensive assessment and interpretation of data is typically the responsibility of the RN.
d. Identifying specific client health problems: Identifying specific client health problems and formulating nursing diagnoses is part of the RN's role. LPNs may assist in collecting data and providing input, but the identification and formulation of nursing diagnoses are within the scope of practice of the RN.
Correct Answer is A
Explanation
A hemoglobin (Hgb) level of 8.8 mg/dL indicates anemia, which is a decrease in the oxygen-carrying capacity of the blood. Fatigue and tiredness are common symptoms of anemia. When the body does not have enough hemoglobin to transport oxygen effectively, it can lead to feelings of fatigue and a lack of energy.
The other options are not directly associated with a low hemoglobin level:
b) "I have noticed that my fingernails are becoming thicker." Thicker fingernails are not typically associated with a low hemoglobin level. Changes in fingernails can be atributed to various factors, but they are not directly related to anemia.
c) "I have to go to the bathroom all the time." Frequent urination is not typically associated with a low hemoglobin level. It can be related to other factors such as urinary tract infections, diabetes, or diuretic use, among others.
d) "I notice that my hands are always shaky." Hand tremors are not directly associated with a low hemoglobin level. Tremors can have various causes, such as neurological conditions, medication side effects, or excessive caffeine intake, but they are not directly linked to anemia.
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