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) Ampicillin: Ampicillin is contraindicated for this client because it belongs to the penicillin class of antibiotics. Since the client is allergic to penicillin, administering ampicillin could trigger an allergic reaction, which could range from mild rash to severe anaphylaxis.
B) Erythromycin: Erythromycin is a macrolide antibiotic and can be used as an alternative for clients who are allergic to penicillin. It is often prescribed for group B streptococcus infections in penicillin-allergic clients, making it a suitable option in this case.
C) Cefazolin: Cefazolin is a cephalosporin antibiotic and is generally considered safe for clients with a penicillin allergy, except in cases of severe penicillin allergies. Cross-reactivity is low, and cefazolin can be an appropriate choice for treating group B streptococcus.
D) Clindamycin: Clindamycin is a lincosamide antibiotic and is often used for clients with penicillin allergies. It is effective against group B streptococcus and does not belong to the penicillin or cephalosporin classes, making it a suitable option for this client.
Correct Answer is A
No explanation
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