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. A Mongolian spot is a benign, pigmented skin mark common in newborns, particularly those with darker skin. It is not related to rubella exposure during pregnancy.
B. Jaundice in the newborn can be a common finding and is not specifically related to maternal rubella exposure. Jaundice often resolves with time or may require treatment, but it is not a direct consequence of rubella.
C. Deafness is a known congenital defect associated with rubella syndrome. Infants exposed to rubella during pregnancy are at risk for serious outcomes, including hearing impairments.
D. Transient strabismus is a common condition in newborns and is not specifically associated with maternal rubella exposure. It typically resolves as the baby grows.

A. A client whose newborn is having difficulty latching-on B. A client who received magnesium sulfate during labor C. A client who has a history of oligohydramnios D. A client whose labor lasted for 6 hr

Correct Answer is B

Explanation

A. A client whose newborn is having difficulty latching-on should be addressed, but this issue is not an immediate postpartum emergency. It is important but does not require urgent intervention compared to potential complications from magnesium sulfate.
B. A client who received magnesium sulfate during labor should be seen first because magnesium sulfate can cause significant side effects like respiratory depression, decreased reflexes, and altered mental status. These effects require close monitoring to prevent severe complications.
C. A client who has a history of oligohydramnios requires monitoring but this history does not necessarily indicate an immediate postpartum issue requiring urgent assessment at this time.
D. A client whose labor lasted for 6 hr does not have an immediate concern solely based on labor duration. While it is relevant, it does not indicate an urgent need for assessment compared to the effects of magnesium sulfate.

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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 caring for a client who is at 39 weeks of gestation and is in active labor. The nurse notes maternal exposure to rubella during pregnancy. After delivery, the nurse should monitor the newborn for which of the following conditions?

Correct Answer is C

Explanation

A nurse has just received change-of-shift report about four clients who are postpartum. Which of the following clients should the nurse plan to see first?

Correct Answer is B

Explanation

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