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 A

Explanation

Choice A rationale:
Poor feeding is a common manifestation in newborns of mothers who used methadone during pregnancy.
Choice B rationale:
A weak cry is not specifically associated with methadone use during pregnancy.
Choice C rationale:
An absent Moro reflex is not specifically associated with methadone use during pregnancy.
Choice D rationale:
A respiratory rate of 30/min is within the normal range for a newborn (30-60 breaths per minute) and does not indicate methadone exposure.

A. Use fingers to exert upward pressure on the presenting part. B. Administer a tocolytic medication. C. Apply oxygen via facemask to the client. D. Wrap the cord in a sterile towel and moisten with warm sterile normal saline.

Correct Answer is A

Explanation

Choice A rationale:
The nurse should use fingers to exert upward pressure on the presenting part to relieve cord compression, which is the immediate priority in this emergency situation.
Choice B rationale:
Administering a tocolytic medication is not the immediate priority. It may be done later to inhibit uterine contractions.
Choice C rationale:
Applying oxygen to the client is important, but it’s not the first action. The nurse needs to relieve cord compression first.
Choice D rationale:
Wrapping the cord in a sterile towel and moistening with warm sterile normal saline is important, but it’s not the first action. The nurse needs to relieve cord compression first.

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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 assessing the newborn of a client who reports methadone use during pregnancy. The nurse should expect the newborn to exhibit which of the following manifestations?

Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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