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 A

Explanation

Choice A rationale:
Yellowed sclera in a newborn could indicate jaundice, which should be reported to the provider.
Choice B rationale:
Stooling after each breastfeeding is normal for a newborn.
Choice C rationale:
Intermittent crossing of eyes is common in newborns and usually resolves by 3 months of age.
Choice D rationale:
Voiding eight to ten times per day is normal for a newborn.

A. Droplet. B. Airborne. C. Protective environment. D. Contact.

Correct Answer is D

Explanation

Choice A rationale:
Droplet precautions are used for diseases or germs that are spread in tiny droplets caused by coughing and sneezing (examples: pneumonia, influenza, whooping cough, bacterial meningitis). This is not the case with Clostridium difficile.
Choice B rationale:
Airborne precautions are used for diseases or germs that are spread through the air (examples: tuberculosis, measles, chickenpox). This is not the case with Clostridium difficile.
Choice C rationale:
A protective environment is a room designed to reduce the risk of infections from airborne, droplet, and contact transmissions. It’s typically for patients who have undergone stem cell transplants. This is not necessary for Clostridium difficile.
Choice D rationale:
Contact precautions are used for diseases or germs that are spread by touching the patient or items in the room (examples: MRSA, VRE, diarrheal illnesses, open wounds). Clostridium difficile is spread via contact, hence contact precautions are appropriate.

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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

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