The home health nurse is visiting a 3-month-old infant who is ...

[Chloeellawright]

The home health nurse is visiting a 3-month-old infant who is diagnosed with congenital hypothyroidism and is prescribed daily levothyroxine. Which should the nurse include in the infant's continued plan of care?
 
  1. Stopping the medication as long as the child continues to grow
  2. Preventing hypothermia with appropriate clothing
  3. Changing formula because it is contraindicated with prescribed medication
  4. Monitoring growth and development without any other prescribed interventions

Question 2

The nurse completes a postpartum assessment on a client who gave birth to her first child 12 hours ago. Assessment findings include: the client nauseated, but has not vomited in the last 2 hours; fundus was boggy but firmed with massage to 1 FB  the uterus; client is experiencing moderately heavy lochia rubra and the perineum ecchymotic and edematous. The client's pain rating is 6 on scale of 1 to 10. Her partner is present and supportive. Breastfeeding has been successful 3 times. Which nursing diagnosis has the highest priority for this client?
 
  1. Acute Pain related to perineal trauma
  2. Risk for Deficient Fluid Volume related to uterine bleeding and nausea
  3. Readiness for Enhanced Family Coping related to vaginal childbirth experience
  4. Knowledge Deficit related to newborn care

[thall411]

Answer to Question 1

2
Explanation:
1. The medication must be continued for life.
2. The parents should be cautioned to dress the child appropriately to prevent hypothermia.
3. The infant formula is not contraindicated with the prescribed medication.
4. The child will continue to need monitoring and intervention even if growth and development are not affected.

Answer to Question 2

2
Explanation:
1. Although this nursing diagnosis is applicable, pain is a lower priority than is risk for fluid volume deficit.
2. Adequate fluid volume is a critical physiologic need; therefore, this is the highest-priority nursing diagnosis.
3. Although this nursing diagnosis may be applicable, family coping is a lower priority than is risk for fluid volume deficit.
4. Although this nursing diagnosis may be applicable, a knowledge deficit is a psychosocial issue, and therefore a lower priority than is the physiologic need for adequate fluid volume.