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:
Offering the parents the opportunity to bathe and dress their baby can provide a sense of normalcy and closure.
Choice B rationale:
This statement assumes the client wants to have another baby and that they will be able to do so, which may not be the case.
Choice C rationale:
It’s important to allow the parents to grieve in their own way. Some may find holding the baby helpful, while others may not.
Choice D rationale:
While naming the baby can provide an identity, it should be the parents’ decision.
Correct Answer is A
Explanation
Choice A rationale:
The McRoberts maneuver involves an obstetrician or other healthcare provider flexing the thighs of a pregnant person toward their abdomen. This maneuver helps to rotate the pelvis and open the sacrum to release the baby’s shoulder.
Choice B rationale:
Applying pressure on the client’s suprapubic area is not part of the McRoberts maneuver. However, when coupled with suprapubic pressure, the effectiveness of the McRoberts maneuver increases to 90%1.
Choice C rationale:
Moving the client onto their hands and knees is not part of the McRoberts maneuver. The maneuver involves pressing the client’s legs against their abdomen.
Choice D rationale:
Applying pressure to the client’s fundus is not part of the McRoberts maneuver. The maneuver involves pressing the client’s legs against their abdomen.
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