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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Related Questions
Correct Answer is B
Explanation
Explanation:
The nurse should respond by recommending that the parent avoids administering aspirin to the child. The use of aspirin in children, especially those under the age of 18, is associated with the risk of developing Reye's syndrome, a rare but serious condition that affects the liver and brain. It is important to educate parents about the potential risks of using aspirin in children, particularly when they have a fever. Instead, the nurse should advise the parent to use appropriate dosages of acetaminophen or ibuprofen based on the child's weight and follow the label directions for administration.
Option a suggests following the label directions based on the child's weight, which may not specifically address the use of aspirin in children and the risk of Reye's syndrome. Option c, stating that the child will require an antibiotic if she develops a fever, is incorrect because antibiotics are not indicated for all fevers and should only be prescribed if there is an underlying bacterial infection. Option d, suggesting that the child can have two baby aspirins every 4 hours, is incorrect and contradicts the recommendation to avoid administering aspirin to the child.
Correct Answer is B
Explanation
The therapeutic relationship can be described in terms of four sequential phases: preinteraction phase, introduction/orientation phase, working phase, and termination phase . In the working phase, most of the therapeutic interventional activities are carried out . This is the phase where the nurse should help the client develop problem-solving skills.
The other options are not correct because:
a) The preinteraction phase starts when the nurse is given the responsibility to start a therapeutic relationship with a patient.
c) The introduction/orientation phase is the first meeting of the nurse with her client (patient).
d) The termination phase is the final stage of the nurse-client relationship.
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