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 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C) A withdrawn parent may indicate emotional distress or difficulty coping with the child's condition, necessitating support and resources.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.
Correct Answer is D
Explanation
Rationale:
A) Maintaining clean technique during dressing changes is essential for preventing infection but is not specific to pain management.
B) Providing low-calorie snacks is unrelated to managing moderate partial-thickness burns.
C) Allowing the child to set their own schedule for wound care might not be appropriate or safe, as wound care should be performed according to healthcare provider recommendations.
D) Ensuring the child receives pain medication prior to therapy helps manage pain associated with dressing changes and other therapeutic interventions.
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