A nurse is preparing to collect a blood specimen from a newborn via a heel stick. Identify the sequence of steps the nurse should follow. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Confirm the newborn's identity.

Cleanse the site with an antiseptic.

Pierce the newborn's heel.

Apply gentle pressure to the site with dry gauze.

Warm the newborn's heel

Answer and Explanation

The Correct Answer is A,E,B,C,D

Proper procedure for a heel stick includes:

A)   Confirming the newborn's identity before any procedure. the nurse should confirm the newborn's identity by checking the identification band and asking the mother or caregiver to verify the name and date of birth.
E) The nurse should warm the newborn's heel by placing a warm compress or a heel warmer on the site for 3 to 5 minutes. This will increase blood flow and reduce pain.
B)   Cleansing the site with an antiseptic to reduce the risk of infection. the nurse should cleanse the site with an antiseptic, such as alcohol or chlorhexidine, and let it air dry. The nurse should avoid using iodine, as it can interfere with some laboratory tests.

C)   The nurse should pierce the newborn's heel with a sterile lancet, making sure to avoid the central area of the heel, where there are more nerves and bones. The nurse should use a single-use device that retracts automatically after use to prevent needlestick injuries.
D)   The nurse should apply gentle pressure to the site with dry gauze to facilitate blood flow and collect the specimen in the appropriate container. The nurse should avoid squeezing or milking the site, as this can cause hemolysis or tissue damage.
E)   The nurse should label the specimen with the newborn's name, date of birth, date and time of collection, and type of test. The nurse should also document the procedure in the newborn's chart, noting any difficulties or complications.

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Correct Answer is ["B","D","F","H"]

Explanation

A) Glucose level might need to be assessed if there are signs of hypoglycemia or other concerns.
B) Mucous membrane assessment: Dry mucous membranes might indicate dehydration or other issues that need further evaluation.
C. Respiratory rate: The respiratory rate is not provided in the assessment, so there's no basis to report it. The assessment did not mention any abnormal respiratory rate.
D) The sclera color indicates that the newborn has jaundice, which is a common condition in newborns but requires monitoring and treatment to prevent complications.
E. Intake and output: Intake and output are not mentioned in the assessment, so there's no basis to report it. This information is not provided in the assessment findings.
F) The Coombs test result is important for assessing the presence of antibodies that could lead to hemolytic disease of the newborn due to blood type incompatibility with the mother, which can also cause jaundice and other serious problems.
G. Heart rate: The heart rate is not mentioned in the assessment, so there's no basis to report it. The assessment did not mention any abnormal heart rate.
H) Head assessment findings, such as soft and flat fontanels along with a molded head, should be communicated for further evaluation. The head assessment finding of caput succedaneum is a swelling of the scalp caused by pressure during delivery, which usually resolves within a few days but can increase the risk of jaundice and infection.

A. Notify the provider. B. Administer a prescribed analgesic C. Assist the client to empty her bladder. D. Monitor perineal pads for clots.

Correct Answer is C

Explanation

A) Incorrect- While notifying the provider might be necessary, addressing bladder distention takes precedence in this scenario.
B) Incorrect- Administering an analgesic might be indicated for pain relief, but addressing bladder distention is the priority.
C) Correct - Assisting the client to empty her bladder is the first action to take. A full bladder can prevent the uterus from contracting properly and can lead to excessive bleeding.
D) Incorrect- Monitoring perineal pads for clots is important but not the first action to take when bladder distention is present.

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A nurse is preparing to collect a blood specimen from a newborn via a heel stick. Identify the sequence of steps the nurse should follow. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["B","D","F","H"]

Explanation

A nurse is caring for a client who had a vaginal delivery 1 day ago. The nurse determines that the client's fundus is firm, located 2 fingerbreadths above the umbilicus, and deviated to the left. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

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