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
Correct Answer is C
Explanation
A. Obtain at least 8 to 10 hours of sleep per night. Adequate sleep is important for overall health, but it is not a primary recommendation for cancer prevention. There is some evidence linking sleep disturbances to cancer risk, but maintaining a healthy weight and exercising have stronger associations with cancer prevention.
B. Refrain from alcohol. Limiting alcohol intake is recommended, but complete abstinence is not necessary for everyone. Moderate alcohol consumption is associated with an increased risk of certain cancers (e.g., breast, liver, esophageal), but maintaining a healthy weight and exercising have broader, more significant cancer prevention benefits.
C. Maintain a healthy weight and exercise regularly. Obesity and a sedentary lifestyle are major risk factors for multiple types of cancer, including breast, colon, and endometrial cancer. Regular physical activity reduces inflammation, improves immune function, and regulates hormones, all of which lower cancer risk.
D. Know the four warning signs of cancer. While recognizing cancer warning signs is important for early detection, prevention strategies are more effective in reducing overall cancer risk. There is no universally agreed-upon list of "four" warning signs, as different cancers present with different symptoms.
Correct Answer is B,D,C,A
Explanation
- Inspect head for trauma. Head injuries can be life-threatening, so the nurse must first assess for signs of skull fractures, concussions, or intracranial bleeding that could explain the headache.
- Perform a neurological exam. If head trauma is suspected, a neurological exam is essential to assess for altered mental status, coordination deficits, or signs of increased intracranial pressure.
- Evaluate range of motion of all joints. After ruling out life-threatening conditions, the nurse should assess for musculoskeletal injuries, fractures, or soft tissue damage from physical abuse.
- Provide a safety plan to prevent further violence. Once the client is medically stable, the nurse should provide resources, assess risk for further harm, and develop a safety plan to prevent future abuse.
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