The nurse observes a mother giving her 11-month-old ferrous sulfate (iron drops), followed by 2 ounces (60 mL) of orange juice. What should the nurse do next?
Suggest placing the iron drops in the orange juice and then feeding the infant.
Give the mother positive feedback about the way she administered the medication.
Instruct the mother to feed the infant nothing for 30 minutes after giving the iron drops.
Tell the mother to follow the iron drops with infant formula instead of orange juice.
The Correct Answer is B
The nurse should give the mother positive feedback about the way she administered the medication. Giving the infant orange juice after administering the iron drops is a good practice because vitamin C in the orange juice can enhance the absorption of iron. The other options (A, C, and D) are not appropriate actions for the nurse to take in this situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Answer: C. Red blood cell count of 2.3 cells/mcl or (2.3 x 10/L).
Rationale:
A. White blood cell count of 10,000/mm³ (10 x 10⁹/L): This is within the normal range for an infant, indicating no immediate concern for infection or immune response. It does not need to be urgently conveyed to the surgeon.
B. Weight gain of 2 pounds (0.91 kg) since birth: This is a positive sign indicating healthy growth and nutritional status, but it is not a critical concern that would affect the immediate surgical plan.
C. Red blood cell count of 2.3 cells/mcl or (2.3 x 10⁹/L): This low RBC count indicates anemia, which is critical information for the surgeon. Anemia can increase the risk of complications during and after surgery due to potential issues with oxygenation and healing, making it the most important information to convey.
D. Urine specific gravity is 1.011: This indicates normal hydration status and is not immediately relevant to the surgical procedure. It does not need to be urgently reported to the surgeon compared to the low RBC count.
Correct Answer is A
Explanation
In a normal infant, T4 levels increase after birth due to stimulation by TSH from the pituitary gland. In this case, the T4 level is low and the TSH level is high, indicating that the thyroid gland is not producing enough T4 in response to TSH stimulation. This suggests that the infant may have congenital hypothyroidism, which requires prompt treatment to prevent developmental delays and other complications.
The low T4 level is not a direct cause of the high TSH level; rather, the high TSH level is a compensatory mechanism to increase T4 production. It is not normal for a breastfeeding infant to have high thyroxine levels. While the thyroid gland may take a few weeks to reach normal function after birth, the persistent low T4 and high TSH levels in this infant suggest a more serious issue.
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