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 B
Explanation
A newborn who was exposed to cocaine in utero may exhibit a high-pitched cry as well as other symptoms such as irritability, tremors, and feeding difficulties.
Choice A is not an answer because hypotonicity is not a common finding in newborns exposed to cocaine in utero.
Choice C is not an answer because increased head circumference is not a common finding in newborns exposed to cocaine in utero.
Choice D is not an answer because decreased startle response is not a common finding in newborns exposed to cocaine in utero.
Correct Answer is C
Explanation
This can be a sign of magnesium toxicity and should be reported to the provider.
Choice A is incorrect because magnesium sulfate is used to treat hypertension associated with preeclampsia.
Choice B is incorrect because a respiratory rate of 16/min is within normal range.
Choice D is incorrect because hyperglycemia is not a known adverse reaction to magnesium sulfate.
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