The nurse is obtaining a health history from parents whose 4-month-old boy has congenital hypothyroidism. What would the nurse most likely assess?
The child has above-normal growth for his age.
The child is active and playful.
The skin is pink and healthy looking.
It is difficult to keep the child awake.
The Correct Answer is D
A. The child has above-normal growth for his age: Congenital hypothyroidism typically results in slowed growth and delayed skeletal maturation due to insufficient thyroid hormone. Above-normal growth is not consistent with this condition and would be unexpected.
B. The child is active and playful: Hypothyroidism in infants usually causes lethargy, hypotonia, and decreased activity. A highly active and playful infant would be atypical and not indicative of untreated congenital hypothyroidism.
C. The skin is pink and healthy looking: Infants with congenital hypothyroidism often have pale, dry, or mottled skin due to decreased metabolism and poor perfusion. Healthy, rosy skin is not a common finding in this condition.
D. It is difficult to keep the child awake: Lethargy and excessive sleepiness are hallmark signs of congenital hypothyroidism in infants. Difficulty keeping the infant awake reflects central nervous system depression caused by thyroid hormone deficiency and is a key clinical indicator.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Spirituality: Spirituality may influence personal beliefs and provide guidance, but it is not the primary factor affecting a teen’s immediate self-esteem during adolescence. Its impact is more indirect and long-term.
B. Confirmation: Positive feedback and recognition from peers, family, and teachers strongly shape a teen’s self-esteem. Adolescents rely on external validation to develop confidence and self-worth during identity formation.
C. Strong authority figures: Authority figures can provide structure and guidance, but their influence on self-esteem is less direct compared with the feedback and acknowledgment received from peers and social interactions.
D. Morals and values: Personal morals and values guide behavior, yet they are more internalized over time and do not have the immediate effect on self-esteem that social confirmation provides.
E. Body image: Body image becomes increasingly important during adolescence, particularly in social settings, but it represents just one aspect of self-esteem and is heavily influenced by the affirmation received from others.
Correct Answer is D
Explanation
A. The cervix is effaced 1 cm: Effacement refers to the thinning of the cervix, measured in percentages from 0% to 100%, not in centimeters. The "-1" notation does not describe cervical effacement.
B. The cervix is 1 cm dilated: Cervical dilation is recorded in centimeters from 0 to 10. The "-1" does not represent cervical dilation and instead relates to fetal station.
C. The presenting part is 1 cm below the ischial spines: Fetal station is measured relative to the maternal ischial spines, ranging from -5 to +5. A negative number indicates the fetus is above the spines, so "-1" is not below the ischial spines.
D. The presenting part is 1 cm above the ischial spines: A fetal station of "-1" indicates that the presenting part of the fetus is 1 cm above the maternal ischial spines, representing early engagement in the birth canal. This measurement helps assess the progress of labor and fetal descent.
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