A nurse is preparing to collect a blood specimen from a newborn via heelstick. Which of the following actions should the nurse take? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
Place a heel warmer on the newborn's heel.
Confirm the identity of the newborn.
Apply pressure to the puncture site with a dry gauze pad.
Label the specimen per facility protocol.
Clean the puncture site with an antiseptic cleanser.
The Correct Answer is B, A, E, C, D
This sequence ensures proper identification, infection control, specimen collection, and safety for the newborn.
Choice A rationale:
The nurse should place a heel warmer on the newborn's heel for 3 to 5 minutes before the heelstick to increase blood flow and facilitate collection.
Choice B rationale:
The nurse should confirm the identity of the newborn before collecting any specimen to ensure patient safety and avoid errors.
Choice C rationale:
The nurse should apply pressure to the puncture site with a dry gauze pad to stop bleeding and promote clotting.
Choice D rationale:
The nurse should label the specimen per facility protocol to ensure accurate identification and processing.
Choice E rationale:
The nurse should clean the puncture site with an antiseptic cleanser to prevent infection and reduce contamination of the specimen.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Referring the client to crisis intervention services might be necessary, but before doing so, the nurse should gather information to understand the client's current situation and coping mechanisms.
Choice B rationale:
Assessing the client's previous coping methods helps the nurse understand the client's strengths and provides insights into potential strategies for managing the crisis effectively.
Choice C rationale:
Discussing the cause of the crisis might be helpful, but it's important to first assess the client's current coping abilities and resources.
Choice D rationale:
Assisting the client in developing strategies to overcome the crisis is important, but it should come after a thorough assessment of the client's current coping mechanisms and situation.
Correct Answer is A
Explanation
Choice A rationale:
Magnesium sulfate is often used to suppress preterm labor by relaxing the uterine smooth muscle.
Choice B rationale:
Methylergonovine is used to prevent or control postpartum hemorrhage and is not typically used for preterm labor.
Choice C rationale:
Calcium gluconate is used to treat magnesium sulfate toxicity and is not typically used for preterm labor.
Choice D rationale:
Dinoprostone is used to ripen the cervix for labor induction, not to suppress preterm labor.
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