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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The action by the AP that indicates an understanding of the procedure is elevating the client's legs before applying the stockings. Elevating the legs can help reduce swelling and make it easier to apply the stockings.
Option b is incorrect because instructing the client to dorsiflex their feet while applying the stockings may not be necessary.
Option c is incorrect because massaging the client's legs before applying the stockings may not be necessary or appropriate.
Option d is incorrect because folding the top of the stockings over after applying them may not be necessary or appropriate.
Correct Answer is C
Explanation
Restlessness is a common sign that a client's pain is not adequately relieved. When a client experience unrelieved pain, they may find it difficult to get comfortable and may exhibit restlessness, such as frequently changing positions, fidgeting, or appearing agitated. It is important for the nurse to assess the client's pain level and address any concerns regarding pain management.
While difficulty swallowing (dysphagia), constipation, and urinary retention can be potential side effects or complications associated with spinal epidural anesthesia, they are not specific indicators of unrelieved pain. These findings may be related to the effects of the anesthesia itself or other factors, and they should still be assessed and addressed by the nurse. However, restlessness is more directly linked to the experience of pain and should be recognized as an important sign that the client's pain relief measures may need adjustment.
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