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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The nurse should clarify the prescription for cefazolin with the provider. Cefazolin is a cephalosporin antibiotic, and there is a risk of cross-reactivity in individuals who have an allergy to penicillin.
a) Doxycycline and b) Vibramycin (which is another name for doxycycline) are tetracycline antibiotics and are not related to penicillin.
d) Gentamicin is an aminoglycoside antibiotic and is also not related to penicillin.
Correct Answer is B
Explanation
b. Rationalization
Explanation:
The correct answer is b. Rationalization.
Rationalization is a defense mechanism characterized by the individual's atempt to justify or explain their behavior or actions in a way that makes it more acceptable to themselves or others. It involves providing logical-sounding reasons or excuses to mask or minimize the real underlying reasons for their behavior.
In this scenario, the client is atributing their recent behavior to the loss of their job, using it as a justification or explanation for their actions. By blaming the job loss, they are rationalizing their behavior as a direct result of the circumstances they faced.
Option a, Projection, involves atributing one's own unacceptable thoughts, feelings, or behaviors to others.
This defense mechanism does not apply to the client's statement about their job loss.
Option c, Repression, involves the unconscious blocking of unwanted thoughts or feelings. It does not relate to the client's behavior or their explanation for it.
Option d, Sublimation, is a defense mechanism where an individual channels or redirects unacceptable impulses or emotions into socially acceptable behaviors or activities. It is not applicable in this context since the client is not expressing their emotions or impulses through alternative constructive means.
By identifying the client's explanation as rationalization, the nurse recognizes the defense mechanism being used and gains insight into how the client is coping with their emotions and justifying their behavior in response to the job loss. This understanding can guide the nurse in providing appropriate support and interventions to help the client manage their anger more effectively.
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