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
Answer: A
Rationale:
A) Serve meals with plastic utensils: Serving meals with plastic utensils is essential to reduce the risk of self-harm. Metal utensils could be used by the client to inflict injury upon themselves, so providing plastic utensils is a necessary safety measure to prevent potential harm.
B) Assign another client to accompany the client to therapy sessions: Assigning another client to accompany the client to therapy sessions is not appropriate as it places an undue burden on another client and may not ensure the safety of the at-risk client. Professional staff should provide supervision and support.
C) Assign the client to a private room: Assigning the client to a private room might increase the risk of self-harm due to reduced supervision. It is generally better to place the client in a more observable setting where staff can frequently monitor their condition.
D) Check on the client every 4 hr: Checking on the client every 4 hours is insufficient for someone who has recently attempted suicide. More frequent monitoring, such as constant or every 15-minute checks, is necessary to ensure the client's safety and provide immediate intervention if needed.
Correct Answer is C
Explanation
MDMA, commonly known as ecstasy or Molly, is a stimulant drug that affects the central nervous system. It primarily acts on serotonin, dopamine, and norepinephrine neurotransmitters. The use of MDMA can lead to altered perception, increased sensory awareness, and hallucinations. Hallucinations may involve visual, auditory, or tactile sensations that are not based on reality.
The other findings mentioned—hypothermia (abnormally low body temperature), somnolence (excessive sleepiness), and muscle weakness—are not typically associated with MDMA use. Instead, MDMA use may lead to increased body temperature (hyperthermia), increased energy levels, agitation, increased heart rate, and muscle tension.
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