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
Explanation
A. Having a fever during the first week at home is not a normal or expected finding and may indicate an infection, requiring further assessment.
B. Contacting the provider for incisional discharge is a proper response.
C. Not having unrelieved pain in the abdomen is an appropriate expectation.
D. Resuming prenatal vitamins is a normal postoperative recommendation.
Correct Answer is C
Explanation
A. Uterine tetany and overproduction of oxytocin are not typically associated with subinvolution.
B. Multiple gestation and postpartum hemorrhage may contribute to uterine atony but not necessarily subinvolution.
C. The most common causes of subinvolution are retained placental fragments and infection.
D. Postpartum hemorrhage may contribute to uterine atony but is not a direct cause of subinvolution.
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