A nurse is preparing to perform a heel stick on a newborn who has a prescription for a total serum bilirubin. Which of the following actions should the nurse take?
Select a 21-gauge needle to perform the procedure.
Apply an alcohol pad to the site after the procedure.
Place a cool cloth at the site for 15 min before the procedure.
Puncture the lateral side of the heel for the procedure.
The Correct Answer is D
Choice A rationale:
A 21-gauge needle is too large for a heel stick on a newborn.
Choice B rationale:
Alcohol can cause skin irritation and should not be used after the procedure.
Choice C rationale:
A warm cloth, not a cool one, should be applied to the site before the procedure to enhance circulation.
Choice D rationale:
The lateral side of the heel is the correct site for a heel stick to avoid injury to the bone.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Breastfeeding is not contraindicated following rubella immunization, so this statement is incorrect.
Choice B rationale:
The rubella vaccine is a single-dose vaccine, not a series of three.
Choice C rationale:
Joint pain can occur following rubella immunization, but it’s not a severe side effect that requires immediate medical attention.
Choice D rationale:
Women are advised to avoid pregnancy for at least 1 month following rubella immunization due to the theoretical risk to the fetus, so this statement is correct.
Correct Answer is B
Explanation
Choice A rationale:
Magnesium sulfate does not increase cardiac output. It is a central nervous system depressant and muscle relaxant.
Choice B rationale:
Magnesium sulfate is given to clients with preeclampsia to prevent seizures, which can be a complication of this condition.
Choice C rationale:
Magnesium sulfate does not directly stabilize the fetal heart rate. Its primary use in preeclampsia is seizure prevention.
Choice D rationale:
While magnesium sulfate can cause vasodilation, which could improve tissue perfusion, its primary use in preeclampsia is to prevent seizures.
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