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 B

Explanation

Choice A rationale
A score of 9 on the Edinburgh Postnatal Depression Screen (EPDS) on postpartum day 2 is below the clinical cutoff score of 10, which is used to distinguish health controls versus possible depression. Therefore, this score would not indicate a high risk of developing a depressive disorder.
Choice B rationale
A score of 11 on the EPDS on postpartum day 30 is above the clinical cutoff score of 1034. This score indicates a high risk of developing a depressive disorder. Therefore, further assessment and possible intervention would be necessary.
Choice C rationale
While discharge teaching is an important aspect of postpartum care, it does not provide information about the client’s risk of developing postpartum depression. Therefore, this choice does not answer the question.
Choice D rationale
A follow-up appointment with a provider in 4 weeks is a standard part of postpartum care, but it does not provide information about the client’s risk of developing postpartum depression.
Therefore, this choice does not answer the question.

A. To facilitate bonding between the newborn and parent. B. The newborn weighs less than 2.5 kg (5.5 lb). C. To allow manifestations of infection to be identified. D. The newborn was delivered via cesarean birth.

Correct Answer is A

Explanation

Choice A rationale
The instillation of antibiotic ophthalmic ointment is delayed to facilitate bonding between the newborn and the parent. Immediate skin-to-skin contact between the newborn and the parent has been shown to have several benefits, including stabilizing the newborn’s heart rate, temperature, and breathing, stimulating digestion, helping the newborn to sleep, promoting weight gain, and aiding in maternal attachment.
Choice B rationale
The newborn’s weight does not affect the timing of the instillation of antibiotic ophthalmic ointment.
Choice C rationale
Manifestations of infection in the newborn’s eyes would not be immediately apparent following birth, so this would not be a reason to delay the instillation of antibiotic ophthalmic ointment.
Choice D rationale
The mode of delivery, whether vaginal or cesarean, does not affect the timing of the instillation of antibiotic ophthalmic ointment.

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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 assessing a postpartum client during a follow-up visit. What was the client’s score on the Edinburgh Postnatal Depression Screen?

Correct Answer is B

Explanation

A nurse is caring for a newborn immediately following birth. For which of the following reasons should the nurse delay the instillation of antibiotic ophthalmic ointment?

Correct Answer is A

Explanation

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