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
A. The nurse's response to have the mother call ensures proper protocol is followed for infant transfer and prioritizes the mother's consent, making it the safest option.
B. While checking identification is important, it does not establish proper protocol for transferring the infant and may not address whether the mother has authorized the transfer.
C. Allowing the grandmother to carry the grandchild without confirming the mother's wishes could lead to security and safety concerns, making this response inappropriate.
D. Allowing the grandmother to push the baby in a wheeled bassinet is not the standard practice; the nurse should ensure that the baby is safely transported by hospital staff.
Correct Answer is C
Explanation
A. Monitoring weight is important for assessing growth but may not be the priority for a
newborn who is small for gestational age (SGA) as it doesn't address immediate physiological needs.
B. Monitoring axillary temperature is important for detecting signs of infection or hypothermia, but it's not the priority for a newborn who is small for gestational age (SGA).
C. Monitoring blood glucose levels is the priority for a newborn who is small for gestational age (SGA) because they are at risk for hypoglycemia due to inadequate glycogen stores.
D. Monitoring intake and output is important for overall assessment but is not the priority intervention for a newborn who is small for gestational age (SGA).
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