A pediatric home care nurse schedules a visit to the home of a 4-week-old newborn who had a low thyroxine (T4) and a high thyroid stimulating hormone (TSH) at birth, and was diagnosed with congenital hypothyroidism or cretinism. Which instruction is most important for the nurse to provide the parents of this child?
Offer a low sodium formula between breast feedings.
Stimulate the infant during feedings to ensure adequate intake.
Administer supplemental thyroid hormone daily.
Monitor the infant's daily intake and weekly weight.
The Correct Answer is C
A. Offer a low sodium formula between breast feedings. Congenital hypothyroidism is not managed with dietary sodium restrictions. The priority is thyroid hormone replacement, not sodium intake adjustments.
B. Stimulate the infant during feedings to ensure adequate intake. Infants with congenital hypothyroidism may have poor feeding due to lethargy, but stimulation during feedings is not the primary intervention. The most critical aspect of care is thyroid hormone replacement to support normal growth and brain development.
C. Administer supplemental thyroid hormone daily. Lifelong thyroid hormone replacement with levothyroxine is essential to prevent intellectual disability and growth delays. Early and consistent treatment ensures normal neurological and physical development. Missing doses or delaying treatment can result in irreversible cognitive impairment.
D. Monitor the infant's daily intake and weekly weight. While monitoring growth and nutrition is important, it is secondary to ensuring proper thyroid hormone therapy, which directly affects metabolism, weight gain, and developmental outcomes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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Explanation
Potential Condition:
Diabetic neuropathy – The client has a history of type 1 diabetes, and her elevated Hemoglobin A1C (8.2%) suggests poor blood glucose control, which increases the risk of diabetic neuropathy.
Actions to Take:
Perform a sensory test on both feet – Diabetic neuropathy can cause loss of sensation in the feet. A sensory test helps assess nerve function and detect early signs of neuropathy.
Instruct the client to change to clean, dry socks – Proper foot care is crucial for preventing infections and complications in clients with diabetes. Keeping feet dry reduces the risk of skin breakdown and infections.
Parameters to Monitor:
Pedal pulses – Poor circulation is a common complication of diabetes and neuropathy. Monitoring pedal pulses helps assess blood flow to the feet.
Blood glucose – Tight glucose control is essential for preventing the progression of diabetic neuropathy. Monitoring blood glucose levels helps guide management and treatment adjustments.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B","dropdown-group-3":"C"}
Explanation
The nurse recognizes that a diagnosis of cellulitis can be explained by assessment findings of red, warm, swollen lower left leg and a small coach (likely wound or abrasion) above the affected area.
Rationale:
Cellulitis is a bacterial skin infection that presents with localized redness, warmth, swelling, and pain.
Red, warm, swollen lower left leg indicates inflammation and infection, which are key signs of cellulitis.
A small coach (likely wound or abrasion) above the affected area suggests a potential entry point for bacteria, increasing the risk of infection.
The client's history of generalized muscle aches and not feeling well suggests systemic involvement, which is common in infections.
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