A one-day-old neonate born at 32 weeks' gestation is in the neonatal intensive care unit under a radiant overhead warmer. The nurse assesses the morning axilla temperature as 95 degrees F (35 degrees C). What could explain the assessment finding?
Conduction heat loss is a problem in the baby.
Axillary temperatures are not accurate.
This is a normal temperature.
The supply of brown adipose tissue is not developed.
The Correct Answer is D
A. Conduction heat loss typically occurs through direct contact with a cooler surface, but in this scenario, the baby is under a radiant warmer, reducing the likelihood of conduction heat loss.
B. Axillary temperatures are generally accurate for newborns when measured properly.
C. A normal temperature for a neonate is between 97 and 99 degrees F (36 to 37 degrees C).
D. Brown adipose tissue is a specialized type of fat that generates heat by metabolizing fatty acids. It is abundant in full-term neonates, but scarce in preterm neonates, especially those born before 34 weeks' gestation. Therefore, preterm neonates have less ability to maintain their body temperature and are prone to hypothermia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. At 9 months of age, babies are able to crawl and explore their environment. They may pick up and put anything in their mouth, which can cause choking or poisoning. Therefore, the nurse should warn the mother about keeping the floor clear of small objects, such as coins, buttons, beads, or toys with detachable parts.
B. Safety procedures during baths are crucial, but this topic may have been covered in earlier visits or could be discussed alongside creating a toddler-safe home.
C. This more relevant for older babies or toddlers who can stand, walk, or climb.
D. Cautioning about putting the baby in a walker is important, but it may not be the most immediate concern at 9 months, as many babies start using walkers around 6-9 months. Creating a safe home environment encompasses a broader range of potential hazards.
Correct Answer is ["A","B","C","D"]
Explanation
A. Asymmetrical movement may indicate discomfort or restricted mobility due to a fractured clavicle.
B. Bruising over the area of the clavicle may suggest trauma and could be associated with a fracture.
C. Edema (swelling) over the fractured clavicle may be present due to inflammation and tissue injury.
D. Facial grimacing with movement could indicate pain or discomfort associated with a fractured clavicle.
E. A positive Babinski reflex is unrelated to a fractured clavicle and would not be directly assessed for this condition.
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