The nurse is collecting a heelstick blood specimen for a neonatal screen, which includes thyroxine (T4) and thyroid stimulating hormone (TSH) levels, prior to the discharge of a 2-day- old client. When the parents ask why these tests are being conducted, which explanation should the nurse provide?

These laboratory values will provide data to anticipate delays in growth and development.

This is a routine blood test required by law to screen for metabolic deficiencies.

Dosages for thyroid replacement therapy will be determined by this test.

This technique is used for early detection of intellectual disabilities.

Answer and Explanation

The Correct Answer is B

A. These laboratory values will provide data to anticipate delays in growth and development.
While abnormal results from these tests could indicate potential developmental issues, the primary purpose of the screening is not to predict delays in growth and development but to identify metabolic deficiencies.

B. This is a routine blood test required by law to screen for metabolic deficiencies.
This is the correct answer. Neonatal screening, including tests for T4 and TSH, is a standard practice mandated by law in many regions to identify metabolic deficiencies such as congenital hypothyroidism early on, ensuring prompt treatment to prevent serious health issues.

C. Dosages for thyroid replacement therapy will be determined by this test.
This explanation might be applicable if a deficiency is detected, but it is not the primary reason for conducting the initial screening. The primary purpose is to identify whether there is a need for treatment.

D. This technique is used for early detection of intellectual disabilities.
Although untreated metabolic deficiencies like congenital hypothyroidism can lead to intellectual disabilities, the primary goal of the screening is to detect and treat these deficiencies before they can cause such problems.

Nursing Test Bank

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Correct Answer is C

Explanation

A. Demonstrating how to palpate the popliteal pulse is not a suitable alternative for measuring blood pressure when the client cannot be measured in the arms or legs. Palpating peripheral pulses does not provide accurate blood pressure measurements.

B. Advising the UAP to document the last blood pressure obtained is insufficient because it does not address the need for current blood pressure monitoring. Documentation of past
measurements does not provide real-time information about the client's hemodynamic status.

C. Estimating the blood pressure by assessing the pulse volume of the client's radial pulses is a reasonable alternative when traditional blood pressure measurement sites are inaccessible. Although not as accurate as traditional methods, assessing the strength of peripheral pulses can provide valuable information about perfusion and blood pressure status.

D. Documenting why the blood pressure cannot be accurately measured is important for record- keeping but does not address the need for ongoing blood pressure monitoring or provide an alternative method for assessment.

A. A Place padding around the cannula tubing. B. B Decrease the flow rate to 1 L/minute. C. C Apply lubricant to the cannula tubing. D. D Discontinue the use of the nasal cannula.

Correct Answer is A

Explanation

A. Placing padding around the cannula tubing is the appropriate intervention to address the erythema under the chin. This padding can help alleviate pressure and reduce skin irritation caused by the tubing. It's a proactive measure to prevent further discomfort or skin breakdown.
B. Decreasing the flow rate to 1 L/minute might not address the issue of pressure-related erythema, and it could compromise the client's oxygenation if not clinically indicated.
C. Applying lubricant to the tubing may not effectively reduce pressure or irritation caused by the tubing under the chin.
D. Discontinuing the use of the nasal cannula should be reserved for situations where it is medically necessary or if an alternative oxygen delivery method is available.

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The nurse is collecting a heelstick blood specimen for a neonatal screen, which includes thyroxine (T4) and thyroid stimulating hormone (TSH) levels, prior to the discharge of a 2-day- old client. When the parents ask why these tests are being conducted, which explanation should the nurse provide?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The unlicensed assistive personnel (UAP) reports that a client's blood pressure cannot be measured in the arms because the client has casts on both arms and is unable to be measured in the legs because the client is in the supine position. Which action should the nurse implement?

Correct Answer is C

Explanation

The nurse observes erythema under the chin of a client receiving oxygen at 2 L/minute per nasal cannula. Which intervention should the nurse implement?

Correct Answer is A

Explanation

After receiving a change of shift report for clients on a medical surgical unit, which task should the nurse assign to the practical nurse (PN)?

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