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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) Incorrect- Oxytocin is not typically administered during a nonstress test.
B) Incorrect- A nonstress test is used to assess fetal well-being and does not indicate Down syndrome.
C) Correct - A lateral tilt position (usually left lateral tilt) is recommended during a nonstress test to prevent compression of the vena cava and maintain proper blood flow to the uterus, which can optimize fetal heart rate monitoring.
D) Incorrect- NPO status is not typically required for a nonstress test. Nonstress tests are non-invasive and do not involve fasting.
Correct Answer is ["B","C","E"]
Explanation
A) Incorrect- Dry, cracked skin is not typically associated with a newborn born at 43 weeks of gestation. It's more common in post-term babies.
B) Correct - Hypotonia (low muscle tone) is a possible finding in post-term newborns due to the aging placenta and potential decrease in amniotic fluid.
C) Correct - Excessive lanugo (fine, downy hair) is more likely to be present in post-term babies as they have less vernix to protect their skin.
D) Incorrect- Absent vernix might be more characteristic of a post-term newborn, but its presence or absence varies widely.
E) Correct - Long, hard nails can be a characteristic of post-term babies, as they have had more time for nail growth in the womb.
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