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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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale:

Abdominal cramps are not typically associated with opioid intoxication. Choice B rationale:

Opioid intoxication can cause symptoms such as slowed or slurred speech, drowsiness, and altered mental status.

Choice C rationale:

Opioid intoxication often leads to bradycardia (slower heart rate), not tachycardia (faster heart rate).

Choice D rationale:

Diaphoresis (excessive sweating) is a symptom of opioid withdrawal, not intoxication.

A. Sodium 140 mEq/L B. Platelet count 350,000/mm3 C. Protein 2 g/dL D. Cholesterol 170 mg/dL

Correct Answer is C

Explanation

Choice A rationale:

The sodium level of 140 mEq/L is within the normal range for children, which is 135 to 145 mEq/L. Sodium levels may be low in nephrotic syndrome due to fluid retention and dilutional hyponatremia, but this is not the case for this child.

Choice B rationale:

The platelet count of 350,000/mm3 is within the normal range for children, which is 150,000 to 450,000/mm3. Platelet levels may be elevated in nephrotic syndrome due to increased production by the bone marrow in response to inflammation and infection, but this is not the case for this child.

Choice C rationale:

The nurse should report the protein level of 2 g/dL to the provider, as this is abnormally low and indicates severe proteinuria. Proteinuria is a hallmark of nephrotic syndrome, as the glomeruli become damaged and allow protein to leak into the urine. Normal protein levels for children are 6 to 8 g/dL. Low protein levels can lead to edema, hypoalbuminemia, and hyperlipidemia.

Choice D rationale:

The cholesterol level of 170 mg/dL is within the normal range for children, which is less than 200 mg/dL. Cholesterol levels may be high in nephrotic syndrome due to increased synthesis by the liver as a compensatory mechanism for low protein levels, but this is not the case for this child.

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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.)

Nursing Test Bank

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Correct Answer is B

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Correct Answer is C

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