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 B
Explanation
A. Notifying the provider may be necessary if the problem persists, but the first step is to address the most likely cause of the deviation.
B. A fundus that is firm but deviated to the left suggests that the bladder may be distended. Emptying the bladder can help the uterus to return to its midline position and promote proper uterine involution.
C. Monitoring perineal pads for clots is important, but the first action should be to resolve the potential cause of the fundal deviation.
D. Administering an analgesic is not a priority action for addressing fundal deviation.
Correct Answer is D
Explanation
A. Wearing an underwire bra is not recommended for breastfeeding mothers, especially those with inverted nipples, as it can cause pressure and discomfort, potentially leading to blocked milk ducts and mastitis.
B. Applying breast cream regularly is not specifically beneficial for inverted nipples. It can help with nipple soreness or dryness, but it does not aid in drawing out inverted nipples.
C. Plastic-lined breast pads can help with leakage but do not address the issue of inverted nipples. They do not assist in reshaping or encouraging the protrusion of the nipples.
D. Placing breast shells in the bra can help draw out inverted nipples by applying gentle, consistent pressure around the areola, which encourages the nipples to protrude, making breastfeeding easier for the newborn.
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