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 B
Explanation
Rationale:
A) It is recommended to use fresh or frozen fruits and vegetables rather than canned due to concerns about added sugars and sodium.
B) Introducing one new food every 5 to 7 days helps identify potential allergies or intolerances and allows the infant's digestive system to adjust to new foods.
C) The amount of solid food introduced initially is typically smaller, usually starting with a teaspoon or so, gradually increasing as the infant gets accustomed to eating solids.
D) Adding rice cereal to a bottle is not recommended as it can increase the risk of choking and does not promote self-feeding skills.
Correct Answer is D
Explanation
A: By the age of 7, most children have a grasp of days and dates as part of their routine. However, not being able to verbalize the date does not necessarily indicate a developmental delay, as it could be related to the child's learning environment or educational opportunities.
B: Counting backwards is a skill that develops with age and practice. A 7-year-old may struggle with this task due to various reasons such as lack of practice, but it is not a definitive sign of a developmental delay.
C: Making change involves complex cognitive skills including math, understanding of money value, and transactions, which may still be developing in a 7-year-old. This skill varies widely among children and is influenced by their experiences with money.
D: The ability to distinguish right from left is a developmental milestone typically achieved by the age of 5 to 6 years. Persistent difficulty in telling the difference between right and left at the age of 7 could suggest a developmental delay in spatial awareness.
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