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 D
Explanation
A. Soft and non-tender breasts are a normal finding in the early postpartum period.
B. A urine output of 3,000 mL in 12 hours is within the normal range.
C. A fundus palpable at the umbilicus may be normal within the first few hours after childbirth.
D. A heart rate of 128/min may indicate a postpartum complication, such as hemorrhage or infection, and requires further assessment.
Correct Answer is C
Explanation
A. Turning the newborn on his side may be done after suctioning but is not the initial priority.
B. Using a suction catheter with low negative pressure may be appropriate, but a bulb syringe is commonly used for newborns.
C.Suctioning the mouth is a necessary step to ensure effective breathing.
D. Suctioningthe nose first may cause the infant to gasp and potentially draw the secretions present in the mouth into the airway, which could lead to aspiration.
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