A nurse is planning to obtain a blood specimen from a newborn via a heel stick.
Which of the following actions should the nurse take?
Cool the newborn's heel prior to the procedure.
Puncture the center of the newborn's heel.
Cleanse the puncture site with alcohol gauze prior to the procedure.
Administer vitamin K 30 minutes prior to each blood draw.
The Correct Answer is C
Choice A rationale
Cooling the newborn’s heel would constrict blood vessels and make it more difficult to obtain a blood sample. Warming the heel is the preferred method to increase blood flow.
Choice B rationale
Puncturing the center of the newborn’s heel is not recommended as it could cause more pain and potential injury to the bone. The puncture should be done on the outer edges of the heel.
Choice C rationale
Cleansing the puncture site with alcohol gauze is essential to reduce the risk of infection and ensure that the sample is not contaminated.
Choice D rationale
Administering vitamin K before each blood draw is unnecessary. Vitamin K is typically given as a one-time dose to prevent bleeding issues, not related to blood draw procedures.
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Correct Answer is C
Explanation
Choice A rationale
Patterned breathing techniques can help in managing pain by focusing on controlled breathing, reducing anxiety, and providing a distraction from the pain, but are not specifically targeting back labor pains.
Choice B rationale
Effleurage involves light circular strokes on the abdomen and can help in managing general labor pain, but may not be as effective specifically for back labor pains.
Choice C rationale
Sacral counterpressure involves applying steady pressure to the sacral area, which can help relieve pain caused by back labor by counteracting the discomfort experienced in this
area.
Choice D rationale
Guided imagery involves using mental visualization to distract from pain and promote relaxation, but may not be as effective in relieving the specific pain associated with back labor.
Correct Answer is D
Explanation
Choice A rationale
Repeating the CST isn't necessary with a negative result, which indicates no significant uterine contractions affecting the fetus.
Choice B rationale
Administering an IV fluid bolus is not warranted by a negative CST result.
Choice C rationale
Preparing for a cesarean birth isn't necessary since a negative CST indicates no immediate fetal distress.
Choice D rationale
A negative CST indicates that there are no late decelerations, so the nurse should allow the labor to progress naturally.