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 ["120"]
Explanation
To calculate the infusion rate in gtt/min, the nurse needs to use the formula: gtt/min = (mL/hr x drop factor) / 60
Plugging in the given values, we get:
gtt/min = (120 mL/hr x 60 gtt/mL) / 60
gtt/min = 7200 gtt/hr / 60 gtt/min = 120 gtt/min
Therefore, the nurse should set the manual IV infusion to deliver 120 gtt/min.
Correct Answer is A
Explanation
A. The nurse should not allow anyone other than the mother or the father to take the newborn to the mother's room. This is to prevent infant abduction, which is a serious threat in hospitals. The nurse should also verify the identity of the mother or the father before handing over the newborn. The nurse should instruct the grandmother to have the mother call and request for the newborn to be brought to her room.
B. This is incorrect because pushing the baby in a wheeled bassinet is not a secure way of transporting the newborn. The bassinet could be easily taken by someone else or accidentally rolled away. The nurse should always accompany the newborn when moving from one place to another.
C. This is incorrect because carrying the grandchild to the room is also not a secure way of transporting the newborn. The grandmother could be stopped by someone who claims to be a staff member and asked to hand over the newborn. The nurse should never let anyone carry the newborn without proper identification and authorization.
D. This is incorrect because showing photo identification is not enough to prove that the person is related to the newborn. The nurse should only allow the mother or the father to take the newborn, and only after verifying their identity with a wristband or a code. The nurse should not rely on photo identification alone, as it could be forged or stolen.
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