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
Chronic constipation is a common finding in clients with hemorrhoids. Constipation can increase pressure on the veins in the rectum and anus, leading to the development of hemorrhoids.
The other options are not correct because:
b) Excessive flatulence is not mentioned as a common finding in clients with hemorrhoids.
c) Frequent stools are not mentioned as a common finding in clients with hemorrhoids.
d) Fecal incontinence is not mentioned as a common finding in clients with hemorrhoids.
Correct Answer is B
Explanation
The client has state-sponsored health insurance: While information about the client's health insurance coverage is important for billing and financial purposes, it may not be directly relevant to the discussion in an interprofessional team meeting unless it specifically impacts the client's access to healthcare resources or affects decision-making regarding their care plan.
The reason for including this information is that difficulty ambulating can impact the client's overall mobility and functional status. It can have implications for their ability to perform activities of daily living, increase the risk of falls, and require additional interventions or resources. By sharing this information with the interprofessional team, appropriate strategies and interventions can be discussed and implemented to address the client's mobility issues.
The client's next dressing change is scheduled in 4 hours: The timing of the client's dressing change may be important for nursing documentation and scheduling purposes. However, it may not be a significant focus of discussion in an interprofessional team meeting unless there are specific concerns or issues related to the dressing change that require collaboration and coordination among the healthcare team.
The client's vital signs are checked every 8 hours: The frequency of vital sign checks is an important aspect of nursing care and monitoring. However, unless there are specific concerns or deviations from normal vital signs that need to be discussed, it may not be the primary information to include in an interprofessional team meeting. The focus of the meeting is typically on broader aspects of the client's condition, care plan, and multidisciplinary interventions.
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