A nurse is preparing to perform a heel stick on a newborn who has a prescription for a total serum bilirubin. Which of the following actions should the nurse take?

Select a 21-gauge needle to perform the procedure.

Apply an alcohol pad to the site after the procedure.

Place a cool cloth at the site for 15 min before the procedure.

Puncture the lateral side of the heel for the procedure.

Answer and Explanation

The Correct Answer is D

Choice A rationale:
A 21-gauge needle is too large for a heel stick on a newborn.
Choice B rationale:
Alcohol can cause skin irritation and should not be used after the procedure.
Choice C rationale:
A warm cloth, not a cool one, should be applied to the site before the procedure to enhance circulation.
Choice D rationale:
The lateral side of the heel is the correct site for a heel stick to avoid injury to the bone.

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Correct Answer is C

Explanation

Choice A rationale:
Human papillomavirus vaccine is not typically administered during pregnancy.
Choice B rationale:
Rubella vaccine is a live vaccine and is generally contraindicated during pregnancy.
Choice C rationale:
Tetanus vaccine is safe and recommended during pregnancy.
Choice D rationale:
Varicella is a live vaccine and is generally contraindicated during pregnancy.

A. "Yellow exudate will form at the surgical site in 24 hours.”. B. "Notify the provider if the end of your baby's penis appears dark red.”. C. "The Plastibell will be removed 4 hours after the procedure.”. D. "Make sure the newborn's diaper is snug.”.

Correct Answer is A

Explanation

Choice A rationale:
Yellow exudate will form at the surgical site in 24 hours, which is a normal part of the healing process.
Choice B rationale:
A dark red appearance of the penis could indicate a complication such as infection or necrosis, which would require medical attention.
Choice C rationale:
The Plastibell is not removed manually; it falls off naturally within 5 to 8 days.
Choice D rationale:
A snug diaper could cause pressure and discomfort on the surgical site; it’s recommended to fasten the diaper loosely.

The Plastibell circumcision technique is one of the most common methods of newborn circumcision. It involves placing a plastic ring under the foreskin and tying a suture around it to cut off blood flow. The foreskin then falls off naturally with the ring in seven to 10 days.

The correct answer is A. The nurse should include that “yellow exudate will form at the surgical site in 24 hours” as part of the teaching to the parents. This is because the yellow exudate is a normal sign of healing and should not be confused with infection.

The other options are incorrect because:

b. The parents should notify the provider if the end of the baby’s penis appears black, not dark red. This could indicate that the ring is too tight and is cutting off blood supply to the glans.
c. The Plastibell will not be removed 4 hours after the procedure. It will stay on the penis until the foreskin falls off naturally in seven to 10 days.
d. The newborn’s diaper should be loose, not snug. This is to prevent the ring from being dislodged or rubbing against the diaper.

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A nurse is preparing to perform a heel stick on a newborn who has a prescription for a total serum bilirubin. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is at 28 weeks of gestation and received no immunizations during childhood. Which of the following vaccines should the nurse plan to administer?

Correct Answer is C

Explanation

A nurse is providing teaching to the parents of a newborn about the Plastibell circumcision technique. Which of the following information should the nurse include?

Correct Answer is A

Explanation

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