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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Correct Answer is C

Explanation

Yellow exudate will form at the surgical site in 24 hours.

After a Plastibell circumcision, the penis might develop a yellow-ish discharge which is a normal side eﬀect that should go away in a few days.

Choice A is incorrect because the foreskin may darken around the ring while it remains on the penis until it falls oﬀ naturally in 7-10 days.

Choice B is incorrect because the plastic ring remains on the penis until foreskin falls oﬀ naturally in 7-10 days.

Choice D is incorrect because there is no information found that suggests making sure the newborn’s diaper is snug after a Plastibell circumcision.

A. Decrease in frequency of contractions. B. Urinary output 35 mL/hr. C. Absent deep-tendon reﬂexes. D. BP 150/100 mm Hg.

Correct Answer is C

Explanation

A nurse should report absent deep-tendon reﬂexes to the provider when a client is receiving magnesium sulfate via continuous IV infusion.

This is because reduced tendon reﬂexes can be a side eﬀect of magnesium sulfate use during pregnancy.

Choice A is not correct because a decrease in the frequency of contractions is an expected outcome of magnesium sulfate use as a tocolytic to stop preterm labor.

Choice B is not correct because a urinary output of 35 mL/hr is within the normal range.

Choice D is not correct because an elevated blood pressure is not a known side eﬀect of magnesium sulfate use during pregnancy.

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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 providing teaching to the parents of a newborn about the Plastibell circumcision technique. Which of the following information should the nurse include?

Correct Answer is C

Explanation

A nurse is assessing a client who is at 32 weeks of gestation and is receiving magnesium sulfate via continuous IV infusion. Which of the following findings should the nurse report to the provider?

Correct Answer is C

Explanation

A nurse is assessing a full-term newborn upon admission to the nursery. Which of the following clinical findings should the nurse report to the provider?

A nurse is caring for a client who is in preterm labor and receiving magnesium sulfate by continuous IV infusion. Which of the following laboratory values should the nurse review during tocolytic therapy?

A nurse is caring for a client who is at 6 weeks of gestation and reports nausea and vomiting. Which of the following recommendations should the nurse make?

A nurse is caring for a newborn who is 6 hours old and has a bedside glucometer reading of 65 mg/dL. The newborn's mother has type 2 diabetes mellitus. Which of the following actions should the nurse take?

A nurse is caring for a client who has a placenta previa. Which of the following findings should the nurse expect?

A nurse is teaching a client about condom use. Which of the following client statements should the nurse identify as an understanding of the teaching?

After completing post anesthesia recovery assessments, the registered nurse (RN) asks the practical nurse (PN) to transfer four clients, each two hours post-birth, to the postpartum unit. Which client should the PN ask the RN to reassess prior to transfer?

A nurse is caring for a client who is in the latent phase of the first stage of labor and is in pain. Which of the following nursing interventions are appropriate to reduce pain? (Select all that apply.)