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.)
Apply a warm cloth to the newborn's heel for 5 to 10 min.
Clean the area with an antiseptic.
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 A,B,C,D,E
Choice A Reason:
Applying a warm cloth to the newborn's heel helps dilate the blood vessels, making it easier to obtain a blood sample by increasing blood flow to the area. This can improve the likelihood of a successful blood draw and minimize discomfort for the newborn.
Choice B Reason:
Cleaning the area with an antiseptic, such as alcohol or iodine solution, helps reduce the risk of introducing bacteria or other contaminants into the puncture site. This step is essential for preventing infection and ensuring the safety of the procedure.
Choice C Reason:
Puncturing the outer aspect of the newborn's heel with a lancet or other sterile device allows access to capillary blood vessels, from which a blood sample can be obtained. This step should be performed quickly and accurately to minimize discomfort and trauma to the newborn.
Choice D Reason:
After puncturing the newborn's heel, blood will start to flow from the capillaries. The nurse should collect the necessary amount of blood into a collection device, such as a microtainer or capillary tube, for laboratory analysis. It's important to ensure proper labeling of the specimen to prevent mix-ups.
Choice E Reason:
After obtaining the blood sample, applying pressure to the puncture site with a dry gauze pad helps promote clotting and minimize bleeding. This step is crucial for preventing excessive bleeding and ensuring the newborn's comfort. The pressure should be applied for an adequate amount of time to allow the blood to clot effectively.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Explanation
Choice A Reason:
Covering the exposed umbilical cord with a sterile saline-saturated towel is an appropriate intervention to prevent the cord from drying out and to reduce the risk of infection. However, this is not the most immediate action that should be taken. The priority is to relieve pressure on the umbilical cord to restore blood flow to the fetus, which is more urgent than covering the cord.
Choice B Reason:
Administering oxygen can help improve maternal oxygenation, which in turn can benefit the fetus. However, in this situation, the immediate priority is to relieve the pressure on the umbilical cord to prevent fetal hypoxia. Administering oxygen is important but secondary to the mechanical relief of cord compression.
Choice C Reason:
This is the most critical and immediate action. Applying upward pressure on the presenting part (e.g., the fetal head) can relieve pressure on the umbilical cord, which is crucial to restore blood flow to the fetus and prevent fetal hypoxia and bradycardia. This action directly addresses the life-threatening situation posed by a prolapsed umbilical cord.
Choice D Reason:
Initiating IV fluids can help maintain maternal blood pressure and support fetal circulation. However, this intervention is not as immediate or directly life-saving as relieving the pressure on the umbilical cord. It can be done after the more urgent interventions are initiated.
Correct Answer is A
Explanation
Explanation
Choice A Reason:
Providing photos of the stillborn fetus is a sensitive gesture that allows the parents to have tangible memories of their child. However, it should be done with sensitivity and only if the parents express a desire for them.
Choice B Reason:
Informing the client that the law requires them to name the fetus is incorrect. There is no legal requirement to name a stillborn fetus. Naming the fetus is a personal decision that should be left to the parents. Pressuring them to name the fetus may cause additional distress.
Choice C Reason:
Limit the amount of time the fetus is in the client's room. This is not an appropriate action. Allowing the parents time to grieve and bond with their stillborn child is important for their emotional healing process. They should be given the opportunity to spend time with the baby if they desire.
Choice D Reason:
Instructing the client that an autopsy should be performed within 24 hours is incorrect. While autopsies can sometimes provide valuable information about the cause of stillbirth, it is not necessary to perform one within 24 hours. The decision to have an autopsy should be discussed with the parents, and the timing can vary depending on their wishes and circumstances.
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