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.)

A. The urinary catheter is usually removed within the first 24 hours after a cesarean birth, not 48 hours. Early removal helps prevent complications and promotes recovery.
B. Uterine massage is performed to prevent postpartum hemorrhage and ensure the uterus is contracting properly. This practice is part of standard postpartum care to promote uterine involution.
C. Postoperative diet progression typically starts with clear liquids and advances as tolerated. Regular food is introduced once the client can swallow safely and shows no signs of nausea or gastrointestinal issues.
D. Staying flat on the back is not required post-cesarean section. Early ambulation is encouraged to prevent complications like deep vein thrombosis and to promote healing.

A. Blood pressure 136/86 mm Hg
- The blood pressure reading is slightly elevated but not critically high. Postpartum hypertension can be a concern, but this level does not indicate an immediate risk.
- This reading is consistent with the earlier measurement, suggesting stability.
- Immediate follow-up is not required unless there is a significant increase or additional symptoms are present.
B. Peripheral edema 2+ bilateral lower extremities
- Edema is common in the postpartum period due to fluid shifts and should resolve naturally.
- The consistent 2+ rating indicates no acute change.
- Monitoring is appropriate, but it does not require immediate follow-up unless it worsens or is accompanied by other symptoms.
C. Lateral deviation of the uterus
- A laterally deviated uterus can indicate a displaced uterus, possibly due to a full bladder or other reasons, which requires prompt attention.
- The deviation from the firm, midline position noted earlier could suggest an underlying issue that needs immediate investigation.
- This finding could lead to complications if not addressed promptly.
D. Breasts soft
- Soft breasts are normal postpartum when milk has not yet come in or if the client is not breastfeeding.
- There is no change from the earlier assessment.
- This does not require immediate follow-up as it is a normal finding.
E. Pain rating of 3 on a scale of 0 to 10
- A pain rating of 3 is mild and manageable, especially considering it was 2 earlier.
- This slight increase in pain is expected and can be monitored with routine care.
- It does not necessitate immediate follow-up unless there is a sudden and significant increase in pain.
F. Uterine tone soft
- A soft uterine tone postpartum can indicate uterine atony, which can lead to hemorrhage.
- The change from a previously firm uterus to a soft one is concerning.
- Immediate follow-up is necessary to prevent potential complications such as postpartum hemorrhage.
G. Large amount of lochia rubra
- A large amount of lochia rubra can be a sign of excessive bleeding.
- The increase from a moderate amount earlier to a large amount could indicate a hemorrhagic complication.
- This finding requires immediate follow-up to assess for postpartum hemorrhage.
H. Deep tendon reflexes 1+
- A deep tendon reflex of 1+ is considered within normal limits.
- There has been no change from the earlier assessment.
- This finding does not require immediate follow-up as it is a normal finding.