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 []

Explanation

- Potential Condition: Placenta previa

- This condition is characterized by the placenta covering the cervix, which can lead to painless, bright red vaginal bleeding during the second or third trimester.

- Actions to Take:

1. Insert a large-bore peripheral IV catheter.

- This is a precautionary measure to ensure that there is immediate venous access for fluid and blood product administration if necessary.

2. Reinforce with the client to maintain bed rest.

- Limiting physical activity can help reduce the risk of further bleeding.

- Parameters to Monitor:

1. Vaginal bleeding

- Monitoring the amount, color, and frequency of bleeding is crucial to assess the ongoing blood loss and stability of the condition.

2. Fetal well-being

- Regular monitoring of fetal heart rate and movement is important to ensure the fetus is not in distress.

A. "You will be tested again for GBS at about 36 weeks of gestation." B. "If you test positive for GBS, the provider will need to perform a cesarean birth." C. "This infection can cause your baby to experience hearing loss at birth." D. "You will take an antibiotic during the last 2 weeks of pregnancy to avoid transferring GBS to your baby."

Correct Answer is A

Explanation

A. Group B Streptococcus (GBS) status is typically re-evaluated at around 36 weeks of gestation to determine if prophylactic antibiotics are needed during labor to prevent transmission to the baby.
B. A positive GBS test does not automatically indicate a cesarean birth. Intravenous antibiotics during labor are generally used to prevent transmission of GBS to the newborn.
C. GBS infection can cause serious complications in newborns, but hearing loss is not a typical outcome. The primary concerns are sepsis, pneumonia, and meningitis.
D. Antibiotics for GBS are given during labor, not the last two weeks of pregnancy. The treatment aims to reduce the risk of GBS transmission to the baby during delivery.

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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

Correct Answer is []

Explanation

A nurse is reinforcing teaching with a client who tested positive for group B streptococcus B-hemolytic (GBS) during a prior pregnancy and is at 30 weeks of gestation. Which of the following statements should the nurse make?

Correct Answer is A

Explanation

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