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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

The nurse should inspect the posterior oropharynx of a child who is frequently swallowing after tonsillectomy to assess for bleeding or the presence of clots. Swallowing frequently can be a sign of postoperative bleeding, which is a potential complication of tonsillectomy.

Touching the tonsillar pillars to stimulate the gag reﬂex or asking the child to speak would not provide information about the presence of bleeding.

Assessing for teeth clenching or grinding is not related to this particular observation.

A. The TSH is high because of the low production of T4 by the thyroid. B. The thyroxine level is low because the TSH level is high. C. The thyroid gland does not produce normal levels of thyroxine for several weeks after birth. D. High thyroxine levels normally occur in breastfeeding infants.

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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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While obtaining the vital signs of a 10-year-old child who had a tonsillectomy this morning, the nurse observes the child swallowing every 2 to 3 minutes. Which assessment should the nurse implement?

Correct Answer is A

Explanation

A breastfeeding infant, screened for congenital hypothyroidism, is found to have low levels of thyroxine (T4) and high levels of thyroid stimulating hormone (TSH). Which is the best explanation for this finding?

Correct Answer is A

Explanation

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