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.
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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Related Questions
Correct Answer is ["A","D","E"]
Explanation
A. The mother is experiencing multiple stressors that may affect her parenting abilities and emotional well-being. She may show signs of depression, such as lack of interest, detachment, irritability, or hopelessness.
B. Voicing pride in the academic accomplishments of her child suggests is highly unlikely. She will not be engaged with her children.
C. Utilizing the correct size of infant car seat is a basic safety measure and may not necessarily indicate the impact of recent stressors on parenting behaviors.
D. This is a possible effect of stress, as the mother may be more likely to seek help or advice from others due to her feeling overwhelmed and incompetent as a parent. Asking for suggestions is a way of showing openness, curiosity, and learning, which are important for the parent's growth and adaptation.
E. Becoming very frustrated and expressing difficulty handling her toddler's temper tantrum may be indicative of increased stress and reduced coping abilities due to recent stressors.
Correct Answer is C
Explanation
A. Obtaining a blood culture may be necessary in certain clinical contexts but is not the priority in this situation.
B. While kangaroo care is beneficial for newborns, it is not the priority when a newborn has a low Apgar score and may require immediate interventions.
C. Beginning resuscitative measures is the priority when a newborn has a low Apgar score at 5 minutes, as it indicates the need for interventions to support breathing and circulation.
D. Initiating IV fluid therapy may be necessary in some cases but is not the priority compared to addressing immediate resuscitative needs.
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