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 A

Explanation

Choice A rationale
Providing the client with a cool sitz bath can help soothe the perineal area, reduce inflammation, and promote healing after a fourth-degree laceration.
Choice B rationale
Administering methylergonovine IM is typically used for the prevention and treatment of postpartum or post-abortion hemorrhage caused by uterine atony or subinvolution. It would not directly address the care of a fourth-degree perineal laceration.
Choice C rationale
Applying a moist, warm compress to the perineum can provide some relief from discomfort, but a cool compress or sitz bath is typically recommended initially after a perineal laceration to help reduce swelling.
Choice D rationale
Applying povidone-iodine to the client’s perineum after she voids is not typically part of the care for a fourth-degree perineal laceration. The area should be kept clean, but routine application of antiseptics is not usually necessary.

A. Hematuria B. BUN 40 mg/dL C. Leukorrhea D. Platelet count 90,000/mm .

Correct Answer is B

Explanation

Choice A rationale
Hematuria, or blood in the urine, is not a normal finding in pregnancy. It could indicate a urinary tract infection, kidney stones, or other kidney problems. However, without more information, it’s not possible to determine the significance of this finding in a client who is at 33 weeks of gestation.
Choice B rationale
A BUN (Blood Urea Nitrogen) level of 40 mg/dL is higher than the normal range, which is between 7 and 20 mg/dL17181920. This could indicate that the kidneys are not working properly. However, it could also be due to a high-protein diet, dehydration, or other factors.
Choice C rationale
Leukorrhea, or vaginal discharge, is a common symptom of pregnancy. It is usually thin, white or clear, and mild smelling. If the discharge is yellow, green, or gray, has a strong smell, or is accompanied by itching or burning, it could indicate an infection.
Choice D rationale
A platelet count of 90,000/mm is lower than the normal range, which is between 150,000 and 450,000/mm25. This could indicate a condition called thrombocytopenia, which can be caused by various conditions, including pregnancy25. However, without more information, it’s not possible to determine the significance of this finding in a client who is at 33 weeks of gestation25.

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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 caring for a client who is 12 hr postpartum and has a fourth-degree laceration of the perineum. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is caring for a client who is at 33 weeks of gestation. The nurse is assessing the client 24 hours later. How should the nurse interpret the findings?

Correct Answer is B

Explanation

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