A nurse is planning care for a newborn who has a new diagnosis of phenylketonuria (PKU).
Which of the following actions should be included in the plan of care?

Administer thyroid hormone replacement.

Educate parents on blood glucose monitoring.

Obtain a blood sample for blood type.

Initiate a controlled low-protein diet.

Answer and Explanation

The Correct Answer is D

A.   Administering thyroid hormone replacement is not indicated for phenylketonuria (PKU). PKU is a metabolic disorder involving the inability to metabolize phenylalanine, an amino acid, and it does not involve thyroid dysfunction.
B.   Blood glucose monitoring is not directly related to the management of PKU. In PKU, the focus is on monitoring and restricting phenylalanine intake, not blood glucose levels.
C.   Obtaining a blood sample for blood type may be necessary for general newborn screening but is not specific to the management of PKU.
D.   Initiating a controlled low-protein diet is the cornerstone of management for PKU. This diet restricts phenylalanine intake, which is essential for preventing neurological damage and
developmental delays in affected infants.

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Correct Answer is B

Explanation

A. Educating the parents about the defect is important for their understanding and involvement in the care of the newborn, but it is not the priority when the infant has a myelomeningocele.
B. Maintaining the integrity of the sac is the priority goal in the care of a newborn with myelomeningocele to prevent infection and protect the exposed neural tissue.

C. Providing age-appropriate stimulation is important for the overall development of the newborn but is not the priority when the infant has a myelomeningocele.
D. Promoting maternal-infant bonding is essential for the emotional well-being of both the
mother and the newborn, but it is not the priority when immediate physical care needs exist, such as maintaining the integrity of the sac.

A. "I'll feed my baby every 2 hours." B. "I'll apply cold compresses 20 minutes before each feeding." C. "I'll try drinking an herbal tea to reduce the engorgement." D. "I'll let my baby drain one breast at each feeding."

Correct Answer is A

Explanation

Feeding the baby every 2 hours helps to ensure frequent emptying of the breasts, which can help alleviate engorgement by reducing milk stasis and promoting milk production regulation.

Applying cold compresses before feeding may temporarily reduce discomfort but does not address the underlying cause of engorgement or promote milk removal.

Drinking herbal tea is not proven to effectively reduce breast engorgement, and it is important for the client to focus on frequent breastfeeding or pumping to alleviate engorgement.

Allowing the baby to drain one breast at each feeding may lead to uneven milk production and exacerbate engorgement. It is important for the client to offer both breasts at each feeding to ensure adequate milk removal from both breasts.

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A nurse is planning care for a newborn who has a new diagnosis of phenylketonuria (PKU). Which of the following actions should be included in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

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Correct Answer is A

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A nurse is planning care for a newborn who has a new diagnosis of phenylketonuria (PKU).
Which of the following actions should be included in the plan of care?