Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
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?
A. Administer thyroid hormone replacement.
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. Educate parents on blood glucose monitoring.
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. Obtain a blood sample for blood type.
Obtaining a blood sample for blood type may be necessary for general newborn screening but is not specific to the management of PKU.
D. Initiate a controlled low-protein diet.
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 anddevelopmental delays in affected infants.
This question is an excerpt from Nurse Dive's nursing test bank - Ati N230 Exam 3 With Ngn Maternal Newborn Proctored Exam. Take the full exam now
Full Explanation
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.
Similar Questions
A nurse is caring for a client who is 1 hour postpartum and observes a large amount of lochia rubra and several small clots on the client's perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take?
A. Document the findings and continue to monitor the client.
The findings described are within the expected range for 1 hour postpartum, as lochia rubra and small clots are normal during the early postpartum period. The firm, midline fundus suggests adequate uterine contraction. Documenting the findings and continuing to monitor the client's progress are appropriate.
B. Increase the frequency of fundal massage.
Increasing the frequency of fundal massage is not necessary as the fundus is already firm and midline.
C. Encourage the client to empty her bladder.
Encouraging the client to empty her bladder is important for uterine involution, but it is not the priority in this scenario, as the fundus is already firm and midline.
D. Notify the client's provider.
Notifying the client's provider is not necessary at this time, as the findings are within theexpected range for the early postpartum period and do not indicate any immediate complications.
Full Explanation
A. The findings described are within the expected range for 1 hour postpartum, as lochia rubra and small clots are normal during the early postpartum period. The firm, midline fundus suggests adequate uterine contraction. Documenting the findings and continuing to monitor the client's progress are appropriate.
B. Increasing the frequency of fundal massage is not necessary as the fundus is already firm and midline.
C. Encouraging the client to empty her bladder is important for uterine involution, but it is not the priority in this scenario, as the fundus is already firm and midline.
D. Notifying the client's provider is not necessary at this time, as the findings are within the expected range for the early postpartum period and do not indicate any immediate complications.
A nurse is caring for a client who is 3 days postpartum and is attempting to breastfeed. Which of the following findings indicate mastitis?
A. A white patch on a nipple
A white patch on a nipple may indicate a fungal infection such as thrush but is not typically associated with mastitis.
B. Cracked and bleeding nipples
Cracked and bleeding nipples are common in breastfeeding but are not specific to mastitis.
C. Swelling in both breasts
Swelling in both breasts can occur with engorgement but is not indicative of mastitis, which typically presents with localized symptoms.
D. Red and painful area in one breast
A red and painful area in one breast is a classic sign of mastitis. Mastitis is an infection of the breast tissue that often presents with localized redness, warmth, swelling, and pain in one breast. Other symptoms may include fever, chills, and flu-like symptoms.
Full Explanation
A. A white patch on a nipple may indicate a fungal infection such as thrush but is not typically associated with mastitis.
B. Cracked and bleeding nipples are common in breastfeeding but are not specific to mastitis.
C. Swelling in both breasts can occur with engorgement but is not indicative of mastitis, which typically presents with localized symptoms.
D. A red and painful area in one breast is a classic sign of mastitis. Mastitis is an infection of the breast tissue that often presents with localized redness, warmth, swelling, and pain in one breast. Other symptoms may include fever, chills, and flu-like symptoms.
A home health nurse is teaching a client who is breastfeeding about managing breast engorgement. Which of the following client statements indicates understanding of the teaching?
A. "I'll feed my baby every 2 hours."
Feeding the baby every 2 hours helps to ensure frequent emptying of the breasts, which can help alleviate engorgement by reducing milk stasis and promoting milk production regulation.
B. "I'll apply cold compresses 20 minutes before each feeding."
Applying cold compresses before feeding may temporarily reduce discomfort but does not address the underlying cause of engorgement or promote milk removal.
C. "I'll try drinking an herbal tea to reduce the engorgement."
Drinking herbal tea is not proven to effectively reduce breast engorgement, and it is important for the client to focus on frequent breastfeeding or pumping to alleviate engorgement.
D. "I'll let my baby drain one breast at each feeding."
Allowing the baby to drain one breast at each feeding may lead to uneven milk production and exacerbate engorgement. It is important for the client to offer both breasts at each feeding toensure adequate milk removal from both breasts.
Full Explanation
Feeding the baby every 2 hours helps to ensure frequent emptying of the breasts, which can help alleviate engorgement by reducing milk stasis and promoting milk production regulation.
Applying cold compresses before feeding may temporarily reduce discomfort but does not address the underlying cause of engorgement or promote milk removal.
Drinking herbal tea is not proven to effectively reduce breast engorgement, and it is important for the client to focus on frequent breastfeeding or pumping to alleviate engorgement.
Allowing the baby to drain one breast at each feeding may lead to uneven milk production and exacerbate engorgement. It is important for the client to offer both breasts at each feeding to ensure adequate milk removal from both breasts.