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 ["1.5"]
Explanation
Calculation:
- Identify the ordered dose and available concentration
Ordered Dose: 30 mg
Available Concentration: 100 mg/5 mL
- Calculate the volume to administer
Volume to administer = (Ordered Dose ÷ Concentration) × Volume of Concentration
Volume to administer = (30 ÷ 100) × 5
Volume to administer = 0.3 × 5
Volume to administer = 1.5 mL
Correct Answer is A
Explanation
A. Recurrent UTI: Frequent urinary tract infections can be a sign of gestational diabetes mellitus (GDM) because hyperglycemia creates an environment conducive to bacterial growth. Recurrent infections may indicate impaired glucose regulation and warrant further screening for GDM.
B. Family history of type 2 diabetes mellitus: While a family history increases the client’s risk for developing GDM, it is not a direct indicator that the client currently has gestational diabetes. It is considered a risk factor rather than a presenting finding.
C. Heart rate is consistently between 55/min and 58/min: A slightly lower maternal heart rate is not indicative of gestational diabetes. Maternal bradycardia in this range is usually not related to glucose metabolism and may be influenced by other factors such as fitness level or medication use.
D. Reports decrease in urination frequency: Gestational diabetes typically causes polyuria rather than decreased urination. Reduced urination is not a characteristic finding associated with GDM and may suggest other renal or hydration issues instead.
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