A nurse is preparing to perform a heel stick on an infant. Which of the following actions should the nurse plan to take to reduce the infant's pain during the procedure?
Apply a cool cloth to the infant's heel 5 min prior to the procedure.
Promote skin-to-skin contact with the infant's guardian during the procedure.
Provide the infant with a bottle of water during the procedure.
Apply lidocaine/prilocaine cream 15 min prior to the procedure.
The Correct Answer is B
A. Apply a cool cloth to the infant's heel 5 min prior to the procedure: Cooling the skin can cause vasoconstriction, making the heel stick more difficult and potentially increasing discomfort. This intervention does not support pain reduction and may prolong the procedure, which can further distress the infant.
B. Promote skin-to-skin contact with the infant's guardian during the procedure: Skin-to-skin contact is an evidence-based method that reduces procedural pain in infants by stabilizing heart rate, enhancing comfort, and lowering stress responses. It offers both analgesic and calming effects, making it an effective strategy during heel sticks.
C. Provide the infant with a bottle of water during the procedure: Water does not provide analgesic benefit to infants and does not activate soothing mechanisms such as the sucrose-induced endorphin release used for pain relief. Offering plain water may also be inappropriate for young infants due to risk of water intoxication.
D. Apply lidocaine/prilocaine cream 15 min prior to the procedure: This topical anesthetic requires significantly longer, typically 30 to 60 minutes, to achieve adequate analgesic effect. Applying it only 15 minutes before the heel stick would not provide sufficient pain control, limiting its effectiveness.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Take this medication at the same time each day: Consistent timing helps maintain stable anticoagulation levels and reduces the risk of under- or over-anticoagulation. Warfarin’s effectiveness and safety depend on steady dosing and adherence to a regular schedule.
B. Take ginger for constipation while on this medication: Ginger can increase the risk of bleeding when taken with warfarin due to its antiplatelet properties. Clients should avoid supplements or herbal remedies that may interact with anticoagulants unless approved by the healthcare provider.
C. Eat foods high in vitamin K: Foods high in vitamin K, such as leafy greens, can decrease the effectiveness of warfarin by promoting clotting. Clients should maintain a consistent intake rather than increasing consumption to avoid fluctuations in anticoagulation levels.
D. Shave with disposable razors: Clients on warfarin are advised to use electric razors instead of disposable or manual razors to reduce the risk of cuts and bleeding. Using disposable razors increases the likelihood of minor injuries that can lead to excessive bleeding.
Correct Answer is B
Explanation
A. The client's shoulders are rounded slightly forward: Slightly rounded shoulders can indicate poor posture or musculoskeletal issues. While minor rounding is common, it is not a defining characteristic of a normal, standard gait and may reflect postural deviations.
B. The client's heels touch the ground before their toes: A standard gait involves initial contact with the heel, followed by a smooth rolling motion to the toes during the stance phase. This heel-to-toe pattern indicates normal foot mechanics and weight transfer, reflecting a healthy, functional gait for ADLs.
C. The client's dominant foot bears more weight: Unequal weight bearing between the dominant and non-dominant foot suggests an abnormal gait or musculoskeletal imbalance. In a normal gait, weight is distributed evenly between both lower extremities during walking.
D. The client looks at the floor when walking: Looking at the floor may indicate visual or balance issues, poor confidence, or gait instability. A standard gait typically involves a forward gaze with a stable, upright posture to maintain balance and coordination.
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