A nurse is preparing to perform a heel stick using a spring-loaded automatic puncture device on a 1-week-old infant. In which of the following locations should the nurse puncture the infant's foot? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)
The Correct Answer is "{\"xRanges\":[93.828125,113.828125],\"yRanges\":[223,243]}"
A. Lateral aspect: The preferred location for performing a heel stick on a neonate is the lateral (outer) aspect of the heel, avoiding the central area and the arch of the foot. This area contains fewer nerve endings and less tissue, making it safer and less painful for the infant. It also minimizes the risk of injury to the underlying bones, blood vessels, and nerves.
B. Heel: The heel is not recommended as a puncture site because it contains fat, bone, and nerves, and puncturing the heel could cause injury or complications such as osteochondritis (bone infection). This site also carries a higher risk of injury to blood vessels and tendons.
C. Medial aspect: The medial (inner) aspect of the heel is also not recommended because it is near the medial plantar artery and nerves. Puncturing this area could result in damage to these structures, leading to complications. The lateral aspect is a safer, preferred location.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Passive range-of-motion exercises should be performed to prevent complications like contractures, but they should be done as ordered by the provider, not automatically every 2 hours.
B. Applying protective padding to the end of the pin sites helps prevent pressure injuries and irritation, which is a key part of maintaining skin integrity and preventing infection.
C. There is no indication that fiber intake should be reduced. In fact, a high-fiber diet is encouraged to prevent constipation, which is a common complication for immobile patients.
D. The traction weights should not be lifted off the floor, as this could interfere with the traction setup and the healing process. Traction should be maintained properly to align and stabilize the fracture.
Correct Answer is C
Explanation
A. The rooting reflex should be present at 1 month of age, not absent. This reflex is triggered when the infant’s cheek is stroked, prompting the baby to turn their head toward the stimulus and open their mouth.
B. A respiratory rate of 64/min is within the expected range for a 1-month-old infant, whose normal respiratory rate is typically between 30–60 breaths per minute.
C. Head lag is normal at 1 month of age when the infant's head is lifted while they are in a sitting position. However, by 4 months of age, the infant should have more head control and reduced head lag.
D. Yellow sclera indicates jaundice, which is common in newborns but should be assessed if present at 1 month to ensure it resolves. By this time, any jaundice should be resolving or gone.
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