A nurse is planning care for a newborn who has a new diagnosis of phenylketonuria (PKU).
Which of the following actions should be included in the plan of care?
Administer thyroid hormone replacement.
Educate parents on blood glucose monitoring.
Obtain a blood sample for blood type.
Initiate a controlled low-protein diet.
The Correct Answer is D
A. Administering thyroid hormone replacement is not indicated for phenylketonuria (PKU). PKU is a metabolic disorder involving the inability to metabolize phenylalanine, an amino acid, and it does not involve thyroid dysfunction.
B. Blood glucose monitoring is not directly related to the management of PKU. In PKU, the focus is on monitoring and restricting phenylalanine intake, not blood glucose levels.
C. Obtaining a blood sample for blood type may be necessary for general newborn screening but is not specific to the management of PKU.
D. Initiating a controlled low-protein diet is the cornerstone of management for PKU. This diet restricts phenylalanine intake, which is essential for preventing neurological damage and
developmental delays in affected infants.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is A.
Rationale for A: Drying the skin is crucial to prevent hypothermia, as newborns can quickly lose body heat. This action also stimulates the newborn and promotes circulation.
Rationale for B: Administering eye prophylaxis is important to prevent gonococcal ophthalmia, but it can be done after ensuring the newborn is warm and stable.
Rationale for C: Placing an identification bracelet is necessary for safety, but it is not as immediate a concern as ensuring the newborn's temperature is regulated.
Rationale for D: Administering vitamin K is important for preventing hemorrhagic disease in newborns, but it can be performed after addressing the newborn's immediate needs, such as warmth.
Correct Answer is D
Explanation
A. Administering oxytocic medication may be necessary to stimulate uterine contractions and control bleeding, but palpating the client's uterine fundus is the priority to assess for uterine atony or excessive bleeding.
B. Increasing the client's fluid intake is important for hydration but does not address the immediate concern of potential postpartum hemorrhage.
C. Assisting the client on a bedpan to urinate is important for comfort and bladder emptying but does not address the priority of assessing and managing postpartum bleeding.
D. Palpating the client's uterine fundus is the priority nursing intervention to assess for uterine atony or excessive bleeding, which could indicate postpartum hemorrhage.
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