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. Microwaving decreases vitamin C content B. Microwaving renders the milk tasteless C. Microwaving does not heat the milk evenly D. Microwaving decreases antiinfective properties E. Microwaving decreases the iron content in the milk

Correct Answer is ["A","C","D"]

Explanation

A. Microwaving breast milk decreases vitamin C content.
B. Microwaving does not render the milk tasteless, but it may alter the taste slightly.
C. Microwaving does not heat breast milk evenly, creating hot spots that can burn the baby's mouth.
D. Microwaving can decrease the antiinfective properties of breast milk.
E. Microwaving breast milk does not decrease iron content.

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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 is teaching a new mother the best method to store milk and use it later for feeding. She explains that the breast milk should never be thawed or heated in a microwave oven because of the following reasons. Please select all that apply

Correct Answer is ["A","C","D"]

Explanation

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