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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Changing the perineal pad of a client who has just been transferred from the labor ward is a task that should not be delegated to an assistive personnel (AP) since it is beyond their scope.
B. Monitoring vital signs during the admission of a client with gestational hypertension requires nursing judgment and assessment skills.
C. Providing a sitz bath to a client with a fourth-degree laceration and is 2 days post- partum can be delegated to an AP. This task does not require the nurse's clinical judgment or assessment skills, and it can be safely performed by the AP following the nurse's instructions.
D. Observing an area of redness on the breast requires nursing assessment and intervention.

A. "I'll apply petroleum jelly to his penis with diaper changes." B. "I'll make sure his diaper is loose in the front." C. "I'll expect the plastic ring to fall off by itself within a couple of days." D. "I'll wash his penis with warm water and mild soap each day."

Correct Answer is B

Explanation

A. Applying petroleum jelly is not recommended with the Plastibell technique as it may interfere with the ring falling off.
B. The client should also keep the diaper loose in the front to prevent pressure or irritation on the penis.
C. The ring to fall off by itself within 5 to 10 days. Do not try to remove it yourself or pull on it.
D. Washing with warm water and mild soap is generally good hygiene but may not be necessary for circumcision care.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse on the postpartum unit is caring for a group of clients with an assistive personnel (AP). Which of the following tasks should the nurse plan to delegate to the AP?

Correct Answer is C

Explanation

A nurse on a postpartum unit is giving discharge instructions to a client whose newborn had a circumcision with the Plastibell technique. Which of the following client statements indicates understanding of circumcision care?

Correct Answer is B

Explanation

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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?

A nurse is caring for a client who is 1 hr postpartum and observes a large amount of lochia rubra and several small clots on the client’s perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take?