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) Using the index finger is a common site for blood glucose monitoring, but it does not specifically address minimizing pain.
B) Holding the finger under warm water can increase blood flow and make blood glucose monitoring less painful.
C) Puncturing the center of the finger pad is a common technique for obtaining a blood sample, but it does not specifically address minimizing pain.
D) Holding the finger against a table is not a recommended method for minimizing pain during blood glucose monitoring and may increase discomfort.
Correct Answer is C
Explanation
Rationale:
A) Inability to hold a bottle is typically achieved by 4-6 months, so it might indicate a developmental delay.
B) Palmar grasp is a primitive reflex typically seen in newborns, and it should be replaced by more voluntary grasping patterns by 8 months.
C) Sitting unsupported is a milestone typically achieved by 6-8 months, indicating expected growth and development at 8 months.
D) Forcing the tongue outward when touched might indicate tongue thrust reflex, which should typically disappear around 4-6 months.
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