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 A
Explanation
Choice A rationale:
Hypnosis can be beneficial if practiced during the prenatal period. It helps the woman to enter labor with a positive mindset and better control over pain.
Choice B rationale:
Hypnosis can indeed work for controlling pain associated with labor when practiced correctly.
Choice C rationale:
Synchronized breathing is not necessarily required during hypnosis. It’s more about focus and relaxation.
Choice D rationale:
Focusing on controlling body functions can be helpful during hypnosis, but it’s not the primary goal of hypnosis.
Correct Answer is ["B","D","E"]
Explanation
Choice A rationale:
Abdominal distention is not typically a sign of hypoglycemia in a newborn. It could be related to other factors such as feeding issues or gastrointestinal problems.
Choice B rationale:
Jitteriness can be a sign of hypoglycemia in a newborn as low blood sugar can cause nervous system hyperactivity.
Choice C rationale:
Acrocyanosis, or bluish discoloration of the hands and feet, is common in newborns and is not typically a sign of hypoglycemia.
Choice D rationale:
Hypotonia, or decreased muscle tone, can be a sign of hypoglycemia in a newborn as low blood sugar can affect muscle function.
Choice E rationale:
Temperature instability can be a sign of hypoglycemia in a newborn as low blood sugar can affect the body’s ability to regulate temperature.
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