The most serious complication of an infant heelstick is necrotizing osteochondritis resulting from lancet penetration of the bone. What approach should the nurse take when performing the test to prevent this complication?
Lancet should penetrate the ball of the foot.
Lancet should penetrate at the outer aspect of the heel.
Lancet should penetrate the area just below the fifth toe.
Lancet should penetrate the walking surface of the heel.
The Correct Answer is B
A. The ball of the foot is not recommended for heelstick procedures.
B. The outer aspect of the heel is the preferred site. This area has fewer nerve endings and less risk of damaging the bone or cartilage.
C. The area below the fifth toe is not a standard site for a heelstick.
D. The walking surface of the heel should be avoided since it is prone to infection, more sensitive, and may interfere with walking.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D","E"]
Explanation
A. Blotting the perineal area dry helps prevent moisture retention, reducing the risk of infection.
B. Performing hand hygiene before and after voiding helps prevent the introduction of bacteria into the perineal area.
C. Applying ice packs may help reduce swelling but is not a routine measure for preventing infection.
D. Cleaning the perineal area from front to back helps prevent the introduction of fecal bacteria into the urethra and vagina.
E. Washing the perineal area using a squeeze bottle of warm water after each voiding helps maintain cleanliness and prevent infection.
Correct Answer is B
Explanation
A. Moderate bright red lochial flow on postpartum day 14 may indicate excessive bleeding and is not indicative of normal involution.
B. A fundus below the symphysis and nonpalpable suggests a well-contracted uterus, which is indicative of normal involution.
C. An episiotomy that is slightly red and puffy on day 14 may indicate ongoing healing, but it is not a direct measure of uterine involution.
D. Breasts that are firm and tender on postpartum day 14 may indicate engorgement, but they are not directly related to uterine involution.
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