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 D
Explanation
Choice A rationale
While it’s true that there may not have been any indication of GBS in earlier prenatal testing, this does not explain why the test was not conducted earlier. GBS can come and go in the body, so a negative test earlier in pregnancy does not guarantee that the woman will still be GBS-negative later in pregnancy.
Choice B rationale
Even if previous deliveries were all negative for GBS, this does not mean that the woman will not have GBS in this pregnancy. GBS can come and go in the body, so each pregnancy is considered separately.
Choice C rationale
GBS is usually asymptomatic in adults, so the woman would not typically report any symptoms of GBS during her pregnancy. This does not explain why the test was not conducted earlier.
Choice D rationale
GBS testing is typically done between 35-37 weeks of gestation. This is because GBS can come and go in the body, so testing during this time frame gives the best prediction of whether or not the woman will have GBS at the time of delivery.
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