A macrosomic infant is born after a difficult forceps-assisted delivery.
After stabilization, the infant is weighed, and the birth weight is 4550 g (9 lbs, 6 ounces). The nurse’s most appropriate action is to:

Assess the parents’ anxiety level and readiness to learn. This is because the nurse needs to evaluate the parent’s emotional state and their ability to comprehend and retain information before providing any teaching.

The nurse should also consider the parent'slearning style, cultural background, and literacy level.

Choice B is wrong because gathering literature for the parents is not the first action. The nurse should first assess the parents’ needs and preferences and then select appropriate materials that match their level of understanding and language.

Choice C is wrong because securing a quiet place for teaching is not the first action. The nurse should first assess the parents’ readiness to learn and then choose a suitable environment that minimizes distractions and promotes comfort.

Choice D is wrong because discussing the plan with the nursing team is not the first action. The nurse should first assess the parents’ anxiety level and readiness to learn and then collaborate with other health care professionals to provide consistent and accurate information.

Verbalizing the importance of monitoring for medication side effects.

Graves’ disease is an autoimmune disorder that causes hyperthyroidism, which means the thyroid gland produces too much thyroid hormone. This can lead to symptoms such as weight loss, increased appetite, nervousness, irritability, insomnia, heat intolerance, and palpitations. The medication methimazole is used to treat Graves’ disease by blocking the synthesis of thyroid hormone. However, methimazole can also cause serious side effects such as liver damage, agranulocytosis (low white blood cell count), and allergic reactions.

Therefore, the priority nursing goal for a 14 year old diagnosed with Graves’ disease is to verbalize the importance of monitoring for medication side effects and reporting them to the health care provider.

Choice A is wrong because relieving constipation is not a priority goal for Graves’ disease. Constipation is more likely to occur in hypothyroidism, which is the opposite of hyperthyroidism.

Choice B is wrong because allowing the adolescent to make decisions about whether or not to take medication is not a priority goal for Graves’ disease. While it is important to respect the adolescent’s autonomy and involve them in their care plan, they also need to understand the risks and benefits of taking medication and the consequences of not taking it.

Choice D is wrong because developing alternative educational goals is not a priority goal for Graves’ disease. Graves’ disease can affect the academic performance of adolescents due to cognitive and emotional changes caused by hyperthyroidism.

However, this does not mean that they need to change their educational goals. They may need extra support and accommodations from their teachers and parents to cope with their condition and achieve their potential.