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 A
Explanation
Choice A rationale
Rear-facing car seats are safer for infants and toddlers because they provide better support for their head, neck, and spine in the event of a collision. The American Academy of Pediatrics recommends keeping children in rear-facing seats until they are at least 2 years old or until they reach the highest weight or height allowed by the manufacturer.
Choice B rationale
A four-point harness is not sufficient for securing a baby in a car seat. A five-point harness, which includes two shoulder straps, two hip straps, and one crotch strap, provides more secure and effective restraint for infants.
Choice C rationale
The shoulder harness should be positioned in the slots at or below the baby's shoulders, not above, to ensure proper fit and restraint. Placing the harness above the shoulders can result in improper restraint and increased risk of injury in an accident.
Choice D rationale
The correct angle for a rear-facing car seat is typically 45 degrees, not 30 degrees. A 45-degree angle ensures the baby's airway remains open, preventing the head from falling forward and potentially causing breathing difficulties.
Correct Answer is D
Explanation
Choice A rationale
Starting each feeding with the most sore breast can worsen the condition, as the infant initially sucks more vigorously at the beginning of a feeding. This might increase the pain and damage to the already sore breast.
Choice B rationale
Moisture-proof lining in breast pads can cause an accumulation of moisture, creating a breeding ground for bacteria. This can exacerbate soreness and lead to infections such as mastitis.
Choice C rationale
Breastfeeding less frequently can lead to engorgement and plugged ducts, which can further complicate breast soreness and potentially decrease milk supply. Regular feeding helps in maintaining milk flow and production.
Choice D rationale
Colostrum has natural healing properties, including immunoglobulins and growth factors, that can help heal sore and cracked nipples. Applying colostrum can promote faster recovery and reduce discomfort.