A small-for-gestational age infant is admitted to the observational care unit with the nursing diagnosis of ineffective thermoregulation related to lack of fat stores as evidenced by persistent low temperatures. Which are appropriate nursing interventions? Select all that apply.

Minimize kangaroo care.

Assess the axillary temperature every hour.

Encourage skin-to-skin contact.

Assess environment for sources of heat loss.

Review maternal history.

Bathe the neonate with warmer water.

Answer and Explanation

Correct Answer : A,B,C,D,E

A.   In small-for-gestational age infants, kangaroo care may increase heat loss due to evaporation, conduction, or convection from the parent's skin or clothing. The nurse should minimize kangaroo care and use other methods of warming such as radiant warmers, incubators, or swaddling.
B.   Assessing the axillary temperature regularly helps monitor the infant's temperature and response to interventions.
C.   Encouraging skin-to-skin contact helps promote thermal regulation and bonding between the infant and parents. Unlike kangaroo care, skin-to-skin contact does not involve covering the infant with clothing or blankets, which can reduce heat loss by radiation or convection. The nurse should encourage skin-to-skin contact when possible and monitor the infant's temperature closely.
D.   Assessing the environment for sources of heat loss is important for minimizing heat loss and promoting thermal regulation.
E.   Reviewing maternal history can provide insights into potential risk factors or contributing factors to the infant's condition, such as maternal age, parity, weight, height, nutrition, smoking, alcohol, drug use, chronic diseases, infections, placental abnormalities, fetal anomalies, or complications during pregnancy or delivery.
F.   Bathing the neonate with warmer water may increase the risk of overheating and should be avoided in infants at risk of thermal instability.

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Correct Answer is D

Explanation

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.

A. A lack of fully developed hearing B. A less discriminating sense of touch C. Visual acuity that has not fully developed D. A less discriminating sense of taste

Correct Answer is D

Explanation

A. Hearing is not directly related to the risk of accidental ingestion.
B. Touch is not typically involved in the identification of substances for ingestion.
C. Visual acuity plays a role in identifying substances but may not directly influence the risk of accidental ingestion.
D. At the age of 3, children may have a less discriminating sense of taste, making them more likely to put potentially harmful substances in their mouths.

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A small-for-gestational age infant is admitted to the observational care unit with the nursing diagnosis of ineffective thermoregulation related to lack of fat stores as evidenced by persistent low temperatures. Which are appropriate nursing interventions? Select all that apply.

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Naxlex Comprehensive Predictor Exams

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?

Correct Answer is D

Explanation

The nurse is providing teaching about accidental poisoning to the family of a 3-year-old. The nurse understands that a child of this age is at increased risk of accidental ingestion due to which sensory alteration?

Correct Answer is D

Explanation

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