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 B
Explanation
A. Covering the cord with the diaper can increase moisture around the stump, leading to delayed cord separation and potential infection.
B. Giving a sponge bath until the cord stump falls off helps to keep the area clean and dry, reducing the risk of infection.
C. Washing the cord daily with mild soap and water is not recommended as it can increase the risk of infection and delay cord separation.
D. Applying petroleum jelly to the cord stump is not recommended as it can trap moisture and increase the risk of infection.
Correct Answer is B
Explanation
A. Pain following a cesarean birth is important to address, but it may not indicate an urgent need for assessment compared to other potential complications.
B. A client with preeclampsia requires close monitoring of blood pressure to prevent
complications such as eclampsia, which can lead to seizures and other serious consequences. An elevated blood pressure reading warrants immediate attention.
C. A client scheduled for discharge following a laparoscopic tubal ligation is stable and can likely wait for assessment until after higher-priority clients have been seen.
D. While it's important to monitor for bleeding after a vaginal birth, the absence of bleeding reported by a client 24 hours postpartum may not indicate an immediate need for assessment compared to the potential urgency of managing preeclampsia.
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