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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

Cesarean birth is not necessarily required for GBS-positive clients as long as IV antibiotic prophylaxis is administered during labor to prevent transmission to the newborn.

Choice B rationale

IV antibiotic prophylaxis, typically with penicillin or ampicillin, is given to GBS-positive clients during labor to prevent neonatal GBS infection.

Choice C rationale

Obtaining a vaginal culture at 39 weeks of gestation is not necessary if the client was already screened and found positive for GBS at 36 weeks.

Choice D rationale

Metronidazole is used to treat bacterial vaginosis or trichomoniasis, not GBS infection; thus, it is not appropriate for this scenario. .

Correct Answer is A

Explanation

Choice A rationale

Checking fetal heart tones is the priority to assess the well-being of the fetus, especially in breech presentation and after the membranes have ruptured.

Choice B rationale

Preparing for a cesarean birth is important but follows the assessment of fetal heart tones and other immediate measures.

Choice C rationale

Checking the color, amount, and odor of the fluid is important, but ensuring fetal heart tones comes first to monitor any distress.

Choice D rationale

Performing a Nitrazine test to assess for rupture of membranes is redundant once the client reports her water has broken.

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