A nurse is preparing to obtain a blood sample from a newborn's heel. In what order should the nurse perform the procedure? (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

Explanation

Choice A Reason:

A heart rate of 89 beats per minute is within the normal range for a postpartum client and does not typically require immediate intervention. However, the nurse should continue to monitor the client's vital signs for any significant changes.

Choice B Reason:

Blood pressure of 120/70 mm Hg is within the normal range for a postpartum client and does not typically require immediate intervention. However, as with other vital signs, ongoing monitoring is essential.

Choice C Reason:

Cool, clammy skin can be indicative of hypovolemia or shock, which can occur postpartum due to excessive bleeding (hemorrhage) or other complications. Therefore, this finding should be reported to the provider promptly for further evaluation and intervention to prevent potential complications.

Choice D Reason:

Moderate lochia serosa is incorrect. Lochia serosa, which is the pinkish-brown vaginal dis charge occurring 3 to 10 days postpartum, is considered normal. Moderate lochia serosa is also within the expected range for this stage of postpartum recovery and does not require immediate intervention. However, if lochia becomes excessive, foul-smelling, or accompanied by signs of infection, it should be reported to the provider for further evaluation.

Explanation

Choice A Reason:

Droplet precautions are used for infectious agents that are transmitted through respiratory droplets. These droplets are generated when an infected person coughs, sneezes, or talks. Examples of diseases requiring droplet precautions include influenza, pertussis (whooping cough), and bacterial meningitis. Methicillin-resistant Staphylococcus aureus (MRSA) is not primarily transmitted through respiratory droplets but rather through direct or indirect contact with infected skin or wounds.

Choice B Reason:

Protective environment precautions, also known as reverse isolation, are used to protect immunocompromised clients from acquiring infections from others. This includes clients who have undergone organ transplantation or chemotherapy. MRSA is not an indication for protective environment precautions because it is not typically transmitted via the air or by casual contact.

Choice C Reason:

Airborne precautions are used for infectious agents that remain infectious over long distances when suspended in the air. Diseases requiring airborne precautions include tuberculosis, measles, and chickenpox. MRSA is not transmitted through the airborne route but rather through direct or indirect contact with contaminated surfaces or skin.

Choice D Reason:

Contact precautions are used for infectious agents that are transmitted by direct or indirect contact with the client or their environment. MRSA is primarily transmitted through direct contact with infected skin or wounds, making contact precautions the appropriate choice. These precautions include wearing gloves and gowns when entering the client's room, performing proper hand hygiene, and ensuring that contaminated items and surfaces are cleaned and disinfected appropriately to prevent the spread of infection to others.