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.

Nursing Test Bank

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Correct Answer is C

Explanation

A. Each feeding should ideally last about 20 to 30 minutes, but it is essential to monitor the baby’s cues for hunger and fullness, rather than strictly adhering to time.
B. Leftover formula from a feeding should not be refrigerated for reuse; it should be discarded to prevent bacterial growth.
C. Prepared formula can indeed be stored in the refrigerator for up to 2 days, making this statement accurate for safe feeding practices.
D. It is recommended to burp the baby during and after feedings, not just at the end, to help release any air swallowed during feeding and prevent discomfort.

A. "Increase the frequency of feedings from the affected nipple." B. "Apply vitamin E oil to the affected nipple before each feeding." C. "Wash the affected nipple with soap and water before each feeding." D. "Expose the affected nipple to the air between feedings."

Correct Answer is D

Explanation

A. Increasing the frequency of feedings from the affected nipple can worsen soreness. It’s important to address the underlying cause of soreness, which may involve evaluating latch technique or positioning rather than increasing feeding frequency.
B. Vitamin E oil is not recommended for sore nipples as it can cause irritation. Proper care involves managing latch and positioning, and sometimes using a lanolin cream rather than oils or other substances.
C. Washing the nipple with soap and water before each feeding can remove natural oils and lead to further irritation. The nipple should be gently cleaned with water, if necessary, and kept clean without over-washing.
D. Exposing the affected nipple to the air between feedings helps with healing and reduces moisture, which can exacerbate soreness. Allowing the nipple to air-dry can promote healing and reduce discomfort.

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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 with a mother who is bottle feeding her newborn with formula. Which of the following statements should the nurse include in the teaching?

Correct Answer is C

Explanation

A nurse is reinforcing teaching with a client who is breastfeeding and reports nipple soreness. Which of the following recommendations should the nurse include in the teaching?

Correct Answer is D

Explanation

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