A nurse is preparing to obtain a blood sample from a newborn’s heel. In what order should the nurse perform the procedure?
Clean the area with an antiseptic
Apply a warm cloth to the newborn’s heel for 5 to 10 minutes
Puncture the outer aspect of the newborn’s heel
Collect the blood specimen
Apply pressure to the site with a dry gauze pad
The Correct Answer is B, A, C, D, E
Step 1 is to apply a warm cloth to the newborn’s heel for 5 to 10 minutes. Warming the heel improves blood flow to the area, making it easier to obtain a blood sample.
Step 2 is to clean the area with an antiseptic. This is to prevent infection.
Step 3 is to puncture the outer aspect of the newborn’s heel. The outer aspect of the heel is less sensitive and less likely to be injured by the lancet.
Step 4 is to collect the blood specimen. After the heel has been punctured, blood will start to flow out and can be collected.
Step 5 is to apply pressure to the site with a dry gauze pad. This is to stop the bleeding after the blood sample has been collected.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice a. Check the client’s serum medication level.
Choice A rationale:
Checking the client’s serum medication level is the most direct and objective method to evaluate medication adherence. It provides a quantifiable measure of the digoxin level in the blood, indicating whether the client is taking the medication as prescribed.
Choice B rationale:
Determining the client’s apical pulse rate is important for monitoring the effects of digoxin, as it can affect heart rate. However, it does not directly measure medication adherence.
Choice C rationale:
Asking the client if they are taking the medication as prescribed relies on self-reporting, which can be inaccurate due to forgetfulness or intentional non-disclosure.
Choice D rationale:
Assessing the client’s kidney function is important for dosing and monitoring potential side effects of digoxin, but it does not directly evaluate medication adherence.
Correct Answer is C
Explanation
Choice A rationale
Polyuria, or excessive urination, is not typically associated with the administration of an epidural block with an opioid analgesic.
Choice B rationale
Bilateral crackles in the lungs can be a sign of a respiratory condition such as pneumonia or heart failure. However, they are not a common side effect of an epidural block with an opioid analgesic.
Choice C rationale
Hypotension, or low blood pressure, is a known side effect of epidural analgesia. This is due to the blockade of the sympathetic chain, which can contribute to hypotension. Therefore, it is important for the nurse to monitor the client’s blood pressure during the administration of an epidural block with an opioid analgesic.
Choice D rationale
Hyperglycemia, or high blood sugar, is not typically a side effect of an epidural block with an opioid analgesic. Hyperglycemia is more commonly associated with conditions such as diabetes.
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