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. Feeding sessions typically last 20 to 30 minutes, allowing the newborn to feed at a comfortable pace and promoting bonding.
B. Formula remaining in the bottle after feeding should be discarded because bacteria from the infant’s mouth can contaminate it; it should not be refrigerated for reuse.
C. Prepared formula can be safely stored in the refrigerator for up to 48 hours only if it has not been fed to the infant; however, once offered, it must be discarded after the feeding.
D. The newborn should be burped periodically during the feeding, such as halfway through and at the end, to reduce swallowed air and discomfort.

A. The newborn's legs flex at the knees and hips when pressure is applied to the soles of the newborn's feet. B. The newborn turns their head away from the stimulus when their cheek is touched. C. The newborn's fingers curl around the nurse's finger when placed in the newborn's palm. D. The newborn closes their eyes and keeps them closed when tapped on the forehead.

Correct Answer is C

Explanation

A. This describes the stepping reflex, which involves the newborn's legs moving in a stepping motion when the soles of the feet touch a surface, not just flexing at the knees and hips. It is expected but not the most relevant to the of reflex elicitation as stated.
B. The newborn turns toward the stimulus when their cheek is touched, not away. This is known as the rooting reflex, which helps the newborn find the breast or bottle for feeding.
C. The newborn's fingers curling around the nurse's finger is the grasp reflex, a normal and expected finding in newborns. It indicates normal neurological development and reflex activity.
D. The newborn blinking in response to a tap on the forehead is known as the glabellar reflex, but they do not typically keep their eyes closed. It is not a primary reflex assessed in newborns for neurological health.

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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

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