A nurse is performing a heel stick on a newborn. Which of the following actions should the nurse take?
Puncture the heel on the inner aspect of the foot.
Use an automatic puncture device on the heel.
Cleanse the newborn's heel with an alcohol swab after the procedure.
Place an ice pack on the newborn's heel 5 min before the procedure.
The Correct Answer is B
“Use an automatic puncture device on the heel.” This is the most common and minimally invasive method to draw capillary blood from an infant for medical testing.
Choice A is incorrect because the heel should be punctured on the outer aspect of the foot to avoid damaging the calcaneus bone.
Choice C is incorrect because the heel should be cleansed with an alcohol swab
before, not after, the procedure.
Choice D is incorrect because there is no need to place an ice pack on the newborn’s heel before the procedure.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The American Academy of Pediatrics (AAP) strongly recommends exclusive breastfeeding for at least 6 months.
Exclusive breastfeeding means that your baby has only breastmilk for 6 months. That means giving your baby breastmilk from your breasts or from botles.
Don’t give your baby water, sugar water, or formula.
The other choices are not recommended:
A. Newborns do not need water between feedings.
C. The length of time a newborn feeds per breast can vary and is not necessarily
limited to 5-10 minutes.
D. Newborns typically have more than two to four wet diapers every 24 hours.
Correct Answer is C
Explanation
A newborn who is 10 hr old and has onset tachypnea.
Tachypnea means rapid breathing and can be a sign of respiratory distress.
Transient tachypnea of the newborn (TTN) is a respiratory disorder usually seen shortly after delivery in babies who are born near or at term.
It is important for the nurse to assess this newborn first to determine the cause of the tachypnea and provide appropriate care.
Choice A, a newborn who is 24 hr old and has not had a meconium stool, may
require further assessment but is not as urgent as a newborn with tachypnea.
Choice B, a newborn who has a short frenulum and is having difficulty breastfeeding, may require assistance with feeding but is not as urgent as a newborn with tachypnea.
Choice D, a newborn who is 30 hr old and has blood-tinged discharge in her diaper, may have pseudomenstruation which is normal and not a cause for concern.
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