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.

Answer and Explanation

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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Free Nursing Study Resources

Correct Answer is A, B, C, D

Explanation

The correct answer is A, B, C, D.

The nurse should plan to perform the following actions in this order:
A. Ask the client to lie on her back and with her knees ﬂexed.
B. Position one hand around the top of the client’s fundus and one hand just above the client’s symphysis pubis.
C. Rotate the upper hand to massage the client’s uterus while using slight downward pressure to compress the fundus.
D. Observe the client’s perineum for the passage of clots and the amount of
bleeding.
Fundal massage is performed to stimulate uterine contractions and prevent
postpartum hemorrhage.

A. "This medication stabilizes the fetal heart rate." B. "This medication improves tissue perfusion." C. "This medication prevents seizures." D. "This medication increases cardiac output.”

Correct Answer is C

Explanation

“This medication prevents seizures.” Magnesium sulfate is a mineral that is given intravenously to women with preeclampsia to reduce the risk of seizures or eclampsia.

Preeclampsia is a condition of high blood pressure and protein in the urine during pregnancy.

Choice A is incorrect because magnesium sulfate does not stabilize the fetal heart rate.

Choice B is incorrect because magnesium sulfate does not improve tissue perfusion.

Choice D is incorrect because magnesium sulfate does not increase cardiac output.

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A nurse is performing a heel stick on a newborn. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to perform a fundal massage for a postpartum client who is experiencing uterine atony. In which order should the nurse plan to perform the following actions?

Correct Answer is A, B, C, D

Explanation

A nurse is providing teaching about the expected eﬀects of magnesium sulfate to a client who is at 28 weeks of gestation and has preeclampsia. Which of the following responses by the nurse is appropriate?

Correct Answer is C

Explanation

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