A nurse is preparing to collect a specimen for newborn screening. Which of the following actions should the nurse take?

Use a lancet to puncture the inner aspect of the newborn's heel.

Leave the newborn's heel open to the air after the puncture.

Apply an antiseptic to the newborn's heel after collecting the specimen.

Warm the newborn's heel for 5 to 10 min before the puncture.

Answer and Explanation

The Correct Answer is A

A)   Correct - Newborn screening typically involves a heel stick using a lancet to collect a few drops of blood from the inner aspect of the newborn's heel.
B)   Incorrect- Leaving the newborn's heel open to the air after the puncture is not necessary; a small bandage is typically applied.
C)   Incorrect- An antiseptic is not typically applied after collecting the specimen, as it could interfere with the accuracy of the screening tests.
D)   Incorrect- Warming the newborn's heel is not a standard step before collecting a specimen for newborn screening.

Nursing Test Bank

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Correct Answer is B

Explanation

A) Incorrect- A 20-gauge needle is too large and could cause unnecessary pain for the newborn.
B) Correct - Choosing a 3/8-inch needle is appropriate for administering vaccines to newborns. he hepatitis B vaccine is given intramuscularly in the anterolateral thigh of newborns. The needle size should be appropriate for the muscle mass and age of the infant. A 3/8-inch needle is recommended for newborns, while a 20-gauge needle is too large and may cause tissue damage.
C) Incorrect- Administering the vaccine into the dorsal gluteal muscle is not recommended because of the risk of injury to the sciatic nerve; the recommended site is the vastus lateralis muscle in the anterolateral thigh.
D) Incorrect- The hepatitis B vaccine is usually administered in a dose of 0.5 mL for newborns, but this is not the only action that the nurse should take.

A. Instruct the client that oxytocin is administered during the procedure. B. Inform the client that this procedure assists in indicating Down syndrome. C. Assist the client to a lateral tilt position prior to the procedure. D. Ensure the client has been NPO for 6 hr prior to the procedure.

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.

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A nurse is preparing to collect a specimen for newborn screening. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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