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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?

A.

Cool the newborn's heel prior to the procedure.

B.

Puncture the center of the newborn's heel.

C.

Cleanse the puncture site with alcohol gauze prior to the procedure.

D.

Administer vitamin K 30 minutes prior to each blood draw.

Answer and Explanation

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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View Related questions

Correct Answer is B

Explanation

Choice A rationale

The fetal heartbeat is typically detectable by Doppler around 10-12 weeks, not as early as 6 weeks.

Choice B rationale

Monthly prenatal visits up to 28 weeks are standard practice for monitoring pregnancy.

Choice C rationale

A complete blood count is not performed at every prenatal visit but at specific intervals.

Choice D rationale

The blood test for neural tube defects, such as AFP, is usually done around 16-18 weeks, not 32 weeks.

Correct Answer is D

Explanation

Choice A rationale

Instituting droplet precautions is not necessary for herpes simplex virus (HSV). HSV is primarily transmitted through direct contact with infected body fluids or lesions, not through respiratory droplets.

Choice B rationale

Administering ceftriaxone sodium is not appropriate for HSV. Ceftriaxone is an antibiotic used to treat bacterial infections, whereas HSV is a viral infection and requires antiviral treatment.

Choice C rationale

Informing the client they should bottlefeed the newborn is not necessary. Mothers with HSV can breastfeed as long as there are no herpetic lesions on the breast. Proper hand hygiene and preventive measures should be taken to avoid transmission.

Choice D rationale

Obtaining surface cultures from the newborn is the appropriate action. This helps in detecting the presence of HSV and initiating antiviral treatment if necessary. Early detection and treatment are crucial in preventing severe complications associated with neonatal HSV infection.

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