The mother of a one-month-old infant calls the clinic to report that the back of her infant's head is flat. How should the nurse respond?
Position the infant on the stomach occasionally when awake and active.
Turn the infant on the left side braced against the crib when sleeping.
Place a small pillow under the infant's head while lying on the back.
Prop the infant in a sitting position with a cushion when not sleeping.
The Correct Answer is A
Choice A reason: Positioning the infant on the stomach occasionally when awake and active is the best response that the nurse can give to the mother. This is because it can help prevent and correct the flat head syndrome, also known as plagiocephaly, by taking pressure off the back of the head and allowing the skull to reshape naturally. It can also promote the infant's motor development and strengthen the neck and shoulder muscles. However, the nurse should also remind the mother to always place the infant on the back when sleeping, as this is the safest position to reduce the risk of sudden infant death syndrome (SIDS) .
Choice B reason: Turning the infant on the left side braced against the crib when sleeping is not a good response that the nurse can give to the mother. This is because it can increase the risk of SIDS, as the infant may roll over to the stomach or suffocate from the bedding or the crib. It can also worsen the flat head syndrome by creating another flat spot on the left side of the head.
Choice C reason: Placing a small pillow under the infant's head while lying on the back is not a good response that the nurse can give to the mother. This is because it can increase the risk of SIDS, as the pillow may cover the infant's face or cause the infant to overheat. It can also interfere with the natural reshaping of the skull and cause neck strain.
Choice D reason: Propping the infant in a sitting position with a cushion when not sleeping is not a good response that the nurse can give to the mother. This is because it can put too much pressure on the spine and the pelvis, which are still developing in the infant. It can also limit the infant's movement and exploration, which are important for learning and development.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Giving prescribed intravenous antibiotics is not the first action that the nurse should take. Antibiotics are used to treat the infection and inflammation caused by appendicitis, but they are not enough to prevent the complications of a ruptured appendix. The nurse should administer the antibiotics as ordered, but only after notifying the healthcare provider of the change in the child's condition.
Choice B reason: Inquiring about the client's last meal is not the first action that the nurse should take. The last meal may be relevant for the preparation of the surgery, but it is not urgent or related to the sudden relief of pain. The nurse should ask about the last meal as part of the preoperative assessment, but only after contacting the healthcare provider.
Choice C reason: Contacting the healthcare provider is the first action that the nurse should take. Sudden relief of pain in a child with appendicitis may indicate a perforation or rupture of the appendix, which is a life-threatening emergency. The nurse should immediately report this finding to the healthcare provider, who may order additional tests or expedite the surgery.
Choice D reason: Documenting the client's relief of pain is not the first action that the nurse should take. Documentation is an important part of nursing care, but it is not a priority in this situation. The nurse should document the child's pain level, vital signs, and interventions, but only after contacting the healthcare provider and taking appropriate actions.
Correct Answer is B
Explanation
Choice A reason: Luteinizing hormone (LH) levels are not relevant for the diagnosis of congenital hypothyroidism. LH is a hormone that regulates the reproductive system and is not affected by thyroid function.
Choice B reason: Thyroxine (T4) is the main hormone produced by the thyroid gland and is essential for growth and development. Low levels of T4 indicate hypothyroidism and require treatment with thyroid hormone replacement. High levels of T4 indicate hyperthyroidism and require treatment with anti-thyroid drugs.
Choice C reason: Growth hormone (GH) levels are not relevant for the diagnosis of congenital hypothyroidism. GH is a hormone that stimulates growth and metabolism and is not affected by thyroid function.
Choice D reason: Follicle stimulating hormone (FSH) levels are not relevant for the diagnosis of congenital hypothyroidism. FSH is a hormone that regulates the reproductive system and is not affected by thyroid function.
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