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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Witch hazel pads can soothe the perineal area and reduce discomfort from an episiotomy and hemorrhoids. This is a common and effective part of postpartum perineal care.
B. Heat packs are not recommended for episiotomy care as they can increase swelling. Instead, cold packs or ice can be used to reduce swelling and discomfort.
C. Numbing sprays should not be used prior to cleansing the area. Instead, gentle cleaning with mild soap and water is recommended for postpartum perineal care.
D. A sitz bath should typically be used for 15 to 20 minutes, not just 10 minutes, to effectively soothe the perineal area and promote healing.

A. "I should expect to have burning when I urinate during the third trimester." B. "I may have an infection if I develop a dark line in the middle of my abdomen." C. "I may develop discoloration on my cheeks from hormonal changes." D. "I should expect my fingers and face to be swollen."

Correct Answer is C

Explanation

A. Experiencing burning during urination is not a normal physiological change during pregnancy and could indicate a urinary tract infection. It is important to report this symptom to a healthcare provider for evaluation and appropriate management.
B. The dark line in the middle of the abdomen, known as the linea nigra, is a common and normal physiological change during pregnancy due to hormonal effects, not an indication of infection. This statement reflects a misunderstanding of normal pregnancy changes.
C. Developing discoloration on the cheeks, often referred to as the "mask of pregnancy" or melasma, is a common and expected physiological change due to hormonal fluctuations. This statement shows that the client understands a normal aspect of pregnancy.
D. Swelling of the fingers and face is not a typical or expected change during pregnancy and could indicate a serious condition such as preeclampsia. While mild swelling of the ankles and feet can be normal, swelling in these areas should be evaluated by a healthcare provider.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching about perineal care to a client who is 2 hr postpartum and has an episiotomy and hemorrhoids. Which of the following statements by the client indicates understanding of the teaching?

Correct Answer is A

Explanation

A nurse in a prenatal clinic is reinforcing teaching with a client about expected physiological changes during pregnancy. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is C

Explanation

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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.)