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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A rationale:
Demonstrating proper bathing of the infant is incorrect. This is a goal for the taking-hold phase, not the taking-in phase.
Choice B rationale:
Verbalizing appropriate car seat safety is incorrect. This is a goal for the taking-hold phase, not the taking-in phase.
Choice C rationale:
Identifying individual family member roles is incorrect. This is a goal for the taking-hold phase, not the taking-in phase.
Choice D rationale:
Having adequate nutritional intake is correct. During the taking-in phase, the mother is focused on her own needs, including nutrition.

A. "This medication increases cardiac output.”. B. "This medication prevents seizures.”. C. "This medication stabilizes the fetal heart rate.”. D. "This medication improves tissue perfusion.”.

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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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client in the postpartum unit. Which of the following goals should the nurse identify for the client to accomplish during the taking-in phase of postpartum adjustment?.

Correct Answer is D

Explanation

A nurse is providing teaching about the expected effects of magnesium sulfate to a client who is at 28 weeks of gestation and has preeclampsia. Which of the following responses by the nurse is appropriate?

Correct Answer is B

Explanation

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