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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A nurse assessing the results of a nonstress test for an antepartal client at 35 weeks of gestation should indicate the need for further diagnostic testing if there are no late decelerations noted with three uterine contractions of 60 seconds in duration within a 10-min testing period.
Choice A is incorrect because an increase in fetal heart rate to 150/min above the baseline of 140/min lasting 10 seconds in response to fetal movement within a 40-min testing period is a normal result.
Choice B is incorrect because irregular contractions of 10 to 20 seconds in duration that are not felt by the client do not indicate the need for further diagnostic testing.
Choice D is incorrect because three fetal movements perceived by the client in a 20-min testing period do not indicate the need for further diagnostic testing.
Correct Answer is D
Explanation
A nurse caring for a client who is receiving prenatal care and is at her 24-week appointment should plan to conduct a one-hour glucose tolerance test.
This test is done to screen for gestational diabetes that can develop during pregnancy.
Choice A, Group B strep culture, is not an answer because it is a test usually done between 35-37 weeks of pregnancy to check for the presence of Group B streptococcus bacteria.
Choice B, Rubella titer, is not an answer because it is a blood test usually done early in pregnancy to check for immunity to rubella.
Choice C, Blood type and Rh, is not an answer because it is a blood test usually done early in pregnancy to determine the mother’s blood type and Rh factor.
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