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 weight gain of 4 kg (10 lb) since the positive pregnancy test, especially at 12 weeks of gestation, may be considered excessive. Typically, during the first trimester, a weight gain of around 1-2 kg (2-4.5 lb) is recommended for women with a normal pre-pregnancy weight. However, individual weight gain recommendations may vary based on factors such as pre-pregnancy weight, height, and medical history.

Choice B Reason:

The client reports that they eat prunes to help manage their constipation. Eating prunes to manage constipation is a healthy dietary choice during pregnancy and does not necessarily indicate a need for a referral to a dietitian. However, it is important to ensure that the client's overall diet is well-balanced and meets their nutritional needs during pregnancy.

Choice C Reason:

The client reports that they take a multivitamin daily. Taking a multivitamin daily is a positive behavior that supports adequate intake of essential vitamins and minerals during pregnancy. While it is important to ensure that the client's prenatal vitamin provides adequate nutrition, this finding alone does not indicate a need for a referral to a dietitian.

Choice D Reason:

The client reports that they are nauseous most mornings. Nausea during pregnancy, particularly in the morning (commonly known as morning sickness), is a common symptom experienced by many pregnant women and does not necessarily indicate a need for a referral to a dietitian. However, the nurse may provide education and support to help manage nausea and ensure adequate nutritional intake despite symptoms.

Explanation

Choice A Reason:

Selecting the lateral side of the finger for puncture is a correct. The lateral side of the finger is often recommended for blood glucose testing as it is less sensitive and typically produces less discomfort for the client compared to other areas of the finger.

Choice B Reason:

Holding the finger above the heart prior to puncture is not necessary for obtaining a blood glucose sample. Holding the finger above the heart could potentially affect the blood flow and result in an inaccurate reading.

Choice C Reason:

Smearing the blood onto the reagent strip is not correct. The blood should be applied directly to the designated area on the reagent strip without smearing to ensure accurate testing.

Choice D Reason:

Puncture the finger while still damp with antiseptic solution is not correct. Puncturing the finger while it is still damp with antiseptic solution can dilute the blood sample and interfere with accurate testing. The finger should be dried thoroughly before obtaining the blood sample.