1. A nurse is obtaining a capillary blood sample from a newborn for phenylketonuria testing. Identify the sequence of steps the nurse should follow. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
Puncture the heel and collect the blood.
Apply pressure with a dry gauze pad.
Wrap a warm, moist cloth around the heel.
Cover the heel with an adhesive bandage.
Cleanse the heel with an antiseptic.
The Correct Answer is C,E,A,B,D
1. Wrap a warm, moist cloth around the heel to dilate the blood vessels, which makes it easier to obtain the blood sample.
2. Cleanse the heel with an antiseptic to reduce the risk of infection at the puncture site.
3. Puncture the heel and collect the blood, ensuring that the sample is adequate for the test.
4. Apply pressure with a dry gauze pad to stop the bleeding from the puncture site.
5. Cover the heel with an adhesive bandage to protect the area and minimize the risk of infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Placing the baby in the bassinet by the bed when using the bathroom does not ensure the baby’s safety. It is important to use the bassinet only as a safe place for the baby, and the baby should not be left unattended or in potentially unsecured areas.
B. Carrying the baby in your arms while walking in the hallway does not prevent abduction and can be risky if you are not vigilant. It is safer to use secure methods for ensuring the baby's safety while moving through the hospital.
C. Ensuring that anyone caring for or transporting your baby is wearing an identification badge is a crucial safety measure. Identification badges help verify that only authorized personnel handle the baby, which helps prevent abductions.
D. If the baby’s identification band slips off, it should be reported immediately to hospital staff rather than being placed in a drawer. The identification band is essential for tracking and ensuring the baby’s safety, so it must be addressed properly to prevent confusion or security issues.
Correct Answer is A
Explanation
A. Chronic hypertension is a significant risk factor for preeclampsia. Pregnant clients with pre-existing high blood pressure are at increased risk for developing this condition, which can lead to complications for both the mother and the baby.
B. Maternal age of 30 years is not considered a high-risk factor for preeclampsia. Advanced maternal age (35 years and older) is more commonly associated with an increased risk.
C. The third pregnancy alone is not a risk factor for preeclampsia. First pregnancies or a history of preeclampsia in previous pregnancies are more relevant risk factors.
D. A prepregnancy BMI of 19 is within the normal weight range and is not associated with an increased risk of preeclampsia. Obesity or a high BMI is more closely linked to the development of preeclampsia.
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