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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.)

Cleanse the heel with an antiseptic.

Cover the heel with an adhesive bandage.

Puncture the heel and collect the blood.

Apply pressure with a dry gauze pad.

Wrap a warm, moist cloth around the heel.

Answer and Explanation

The Correct Answer is E,A,C,D,B

Wrap a warm, moist cloth around the heel.
Cleanse the heel with an antiseptic.
Puncture the heel and collect the blood.
Apply pressure with a dry gauze pad.
Cover the heel with an adhesive bandage. .

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Correct Answer is D

Explanation

Choice A rationale

Nausea can be a side effect of magnesium sulfate, but it is not a specific indication of toxicity. Other symptoms are more directly indicative of magnesium sulfate overdose.

Choice B rationale

Facial flushing is a common side effect of magnesium sulfate but is not a sign of toxicity. It typically occurs at therapeutic levels and is not a reliable indicator of overdose.

Choice C rationale

Urine output of 40 mL/hr is within normal limits for an adult and does not indicate magnesium sulfate toxicity. However, significantly decreased urine output could be concerning.

Choice D rationale

Respiratory rate of 10/min is a critical sign of magnesium sulfate toxicity. Magnesium sulfate can cause respiratory depression, and a rate of 10 breaths per minute or less indicates that the patient may be experiencing toxic effects, necessitating immediate medical intervention.

Correct Answer is ["0.25"]

Explanation

Step 1 is (0.5 mg ÷ 1 mg) × 0.5 mL

Step 2 is 0.5 ÷ 1 = 0.5

Step 3 is 0.5 × 0.5 mL

Step 4 is 0.25 mL

Answer: 0.25 mL

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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 assisting with the care of a client who received magnesium sulfate to treat preterm labor.The nurse should monitor the client for which of the following findings as an indication of magnesium sulfate toxicity?

Correct Answer is D

Explanation

A nurse is preparing to administer phytonadione 0.5 mg IM to a newborn. The amount available is phytonadione 1 mg/0.5 mL. How many mL should the nurse plan to administer? (Round the answer to the nearest hundredth. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["0.25"]

Explanation

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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.)