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
A. The FLACC pain rating scale is appropriate for infants and young children, assessing pain based on Face, Legs, Activity, Cry, and Consolability, making it suitable for a 5-month-old infant.
B. The COMFORT pain rating scale is generally used for children who are unable to communicate their pain, typically in older children or adolescents, and is less suitable for this age group.
C. The FACES pain rating scale is designed for children aged 3 and older who can identify facial expressions but is not appropriate for a 5-month-old infant.
D. The CRIES pain rating scale is also used for infants but is more specific to neonates (0-6 months) and measures crying, oxygen requirement, increased vital signs, and facial expressions, making it less applicable than the FLACC scale for this specific postoperative context.
Correct Answer is C
Explanation
Rationale:
A) Involvement of a grandparent in assisting with activities of daily living (ADLs) indicates family support.
B) The child engaging in play with siblings suggests social interaction and family involvement.
C) A withdrawn parent may indicate emotional distress or difficulty coping with the child's condition, necessitating support and resources.
D) The step-parent's involvement in preparing the child for school transition indicates family support and engagement in the child's development.
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