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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 A

Explanation

Choice A rationale

An indwelling urinary catheter can increase the risk of falls because it may cause discomfort and restricted mobility, leading the client to move awkwardly or lose balance.

Choice B rationale

While a second-degree perineal laceration might cause pain and limited mobility, it doesn't usually contribute as significantly to fall risk as an indwelling catheter.

Choice C rationale

Saturating a perineal pad every 5 to 6 hours may indicate heavy postpartum bleeding, but it isn't directly related to fall risk. The concern here would be more about monitoring for hemorrhage rather than falls.

Choice D rationale

Breast engorgement causes discomfort and pain but doesn't directly affect a client's mobility or balance, making it less likely to increase fall risk.

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.

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