A nurse is preparing to obtain a blood sample from a newborn’s heel. In what order should the nurse perform the procedure?

Clean the area with an antiseptic

Apply a warm cloth to the newborn’s heel for 5 to 10 minutes

Puncture the outer aspect of the newborn’s heel

Collect the blood specimen

Apply pressure to the site with a dry gauze pad

Answer and Explanation

The Correct Answer is B, A, C, D, E

Step 1 is to apply a warm cloth to the newborn’s heel for 5 to 10 minutes. Warming the heel improves blood flow to the area, making it easier to obtain a blood sample.

Step 2 is to clean the area with an antiseptic. This is to prevent infection.

Step 3 is to puncture the outer aspect of the newborn’s heel. The outer aspect of the heel is less sensitive and less likely to be injured by the lancet.

Step 4 is to collect the blood specimen. After the heel has been punctured, blood will start to flow out and can be collected.

Step 5 is to apply pressure to the site with a dry gauze pad. This is to stop the bleeding after the blood sample has been collected.

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Correct Answer is C, A, D, E, B

Explanation

The Leopold maneuvers are a common and systematic way to determine the position of a fetus inside the woman’s uterus. They are typically performed at prenatal examinations during the third trimester of pregnancy. Here is the correct sequence of actions a nurse should take: Instruct the client to empty their bladder. This is done to make the examination easier and more comfortable for the client ©. Position the client supine with knees flexed and place a small, rolled towel under one of their hips. This position helps relax the abdominal muscles and displaces the uterus to the side, reducing the risk of supine hypotensive syndrome (a). Palpate the fetal part positioned in the fundus. This helps determine the fetal lie and presentation (d). Palpate the fetal parts along both sides of the uterus. This helps identify the location of the fetal back and small parts (e). Palpate the fetal part positioned above the symphysis pubis. This helps determine the fetal attitude and degree of extension or flexion of the fetal head (b). Remember, these maneuvers should be performed gently and respectfully, with the nurse explaining each step to the client. The goal is to assess the position and presentation of the fetus, as well as estimate fetal weight, not to change the position of the fetus. If the nurse is unsure about the position or presentation of the fetus, an ultrasound may be needed for confirmation.

A. Peripheral edema 2+ in bilateral lower extremities B. Blood pressure reading of 136/86 mm Hg C. Lateral deviation of the uterus D. Deep tendon reflexes 1+ E. Large amount of lochia rubra .

Correct Answer is ["B","C","E"]

Explanation

Choice A rationale
Peripheral edema 2+ in bilateral lower extremities is a common finding in the postpartum period and does not necessarily indicate a problem. It can result from the normal fluid shifts that occur after delivery.
Choice B rationale
A blood pressure reading of 136/86 mm Hg is slightly elevated and could indicate the development of postpartum hypertension, a condition that can lead to serious complications such as stroke. This finding necessitates immediate follow-up.
Choice C rationale
Lateral deviation of the uterus could indicate a full bladder, which can interfere with uterine contractions and lead to increased bleeding. This finding necessitates immediate follow-up.
Choice D rationale
Deep tendon reflexes 1+ are within normal limits and do not necessitate immediate follow-up.
Choice E rationale
A large amount of lochia rubra could indicate postpartum hemorrhage, a potentially life- threatening condition. This finding necessitates immediate follow-up.

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A nurse is preparing to obtain a blood sample from a newborn’s heel. In what order should the nurse perform the procedure?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to perform Leopold maneuvers on a client who is at 36 weeks of gestation. Identify the sequence of actions the nurse should take.

Correct Answer is C, A, D, E, B

Explanation

A nurse has been monitoring a client who gave birth vaginally 8 hours ago. Based on the nurse’s notes at 0700 and 1100, select the three findings that necessitate immediate follow-up.

Correct Answer is ["B","C","E"]

Explanation

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