A nurse is preparing to perform a heel stick on an infant. Which of the following actions should the nurse take?
Use an automated lancet device to puncture the heel.
Apply limb restraints to the infant.
Puncture the heel at the inner aspect of the heel.
Cleanse the area with povidone iodine.
The Correct Answer is A
Rationale:
A) Using an automated lancet device provides a controlled and consistent depth of puncture for the heel stick, minimizing discomfort and risk of injury.
B) Applying limb restraints is unnecessary and could cause distress to the infant.
C) Puncturing the heel at the inner aspect may not be the appropriate site for the heel stick.
D) Cleansing the area with povidone iodine is not necessary for a routine heel stick procedure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A) Offering a pacifier can help soothe a fussy baby with colic.
B) Offering water in between feedings is not recommended for infants, especially at 1 month old, as it can interfere with proper feeding and increase the risk of water intoxication.
C) Placing a warm heating pad on the baby's abdomen is not recommended without specific guidance from a healthcare provider and can pose a risk of burns.
D) Allowing the baby to cry for 5 minutes before responding is not recommended for infants, as it can lead to increased stress and distress.
Correct Answer is B
Explanation
Rationale:
A) Weight loss is a common side effect of methylphenidate, so expecting the child to gain weight would not be accurate.
B) Using charts to assist with organizing the child's day is a helpful strategy for managing ADHD symptoms and promoting organization and structure.
C) Alternating the study area weekly may not provide the consistency and routine that can be beneficial for children with ADHD.
D) Methylphenidate is typically taken on a regular schedule, rather than as needed, to maintain consistent therapeutic levels in the bloodstream.
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