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 A
Explanation
A. Recurrent urinary tract infections are a contraindication for using a diaphragm because the presence of a foreign object in the vagina can increase the risk of UTIs.
B. Tobacco use is a risk factor for cardiovascular issues with hormonal contraceptives but not for barrier methods like diaphragms.
C. History of positive group B streptococcus B-hemolytic is a concern for newborn care and labor management, but it is not a contraindication for the use of a diaphragm.
D. Deep-vein thrombosis is a contraindication for hormonal contraceptives due to an increased risk of clotting but does not affect the use of diaphragms, which are a barrier method of contraception.
Correct Answer is []
Explanation
- Potential Condition: Endometritis. The symptoms of malaise, chills, decreased appetite, elevated temperature, tachycardia, a boggy and tender uterus, and foul-smelling lochia are indicative of a postpartum infection, such as endometritis.
- Actions to Take:
- Monitor the lochia amount and odor: This will help assess the presence of infection and the effectiveness of treatment.
- Assist with the administration of prescribed antibiotics: Antibiotics are the primary treatment for endometritis.
- Parameters to Monitor:
- Temperature: Monitoring for fever can help assess the response to treatment and indicate if the infection is resolving or worsening.
- Heart rate: Tachycardia may be a sign of infection or other complications, so it's important to monitor changes in heart rate.
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