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:
Administering corticosteroids is relevant for clients at risk of preterm labor, not specifically for placenta previa.
Choice B rationale:
Placenta previa can lead to bleeding and potential fetal distress. Continuous monitoring of fetal heart rate (FHR) and uterine contractions is essential to promptly identify any signs of distress.
Choice C rationale:
Terbutaline is a tocolytic medication used to suppress uterine contractions, and it's not relevant for managing uterine atony associated with placenta previa.
Choice D rationale:
Performing a vaginal exam can further increase the risk of bleeding in cases of placenta previa and is generally contraindicated due to the risk of disturbing the placental site.
Correct Answer is C
Explanation
Choice A rationale:
Drowsiness is not a common side effect of phentermine/topiramate.
Choice B rationale:
An irregular menstrual cycle is not a common side effect of phentermine/topiramate.
Choice C rationale:
Phentermine/topiramate is a medication used to assist with weight loss. Topiramate, one of the components of this medication, can increase the risk of birth defects if taken during pregnancy. Therefore, it is important for women of childbearing age to avoid becoming pregnant while on this medication and to use effective contraception.
Choice D rationale:
Loose stools are a potential side effect of phentermine/topiramate, but this statement does not necessarily indicate an understanding of the medication's purpose and precautions.
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