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 C

Explanation

A. This statement doesn't demonstrate understanding of appropriate feeding practices for a 5-month-old.
B. While pureeing food is a method of introducing solid foods, it doesn't specifically address the appropriate consistency or type of food.
C. Introducing cereal with a thin consistency is appropriate as a first solid food for a 5-month-old.
D. Starting with baby oatmeal cereal mixed with low-fat milk may not be appropriate as cow's milk is not recommended before the age of 1.

A. Surgery to correct the joint and muscle alignment B. Immobilization of the shoulder and arm C. Physical therapy to the joint and extremity D. Nothing but time and let nature take its course

Correct Answer is C

Explanation

A. Surgery may be considered in severe cases or if conservative treatments fail, but it is not typically the first-line treatment for Erb's palsy.
B. Immobilization may be part of the treatment plan in some cases, but it is usually accompanied by physical therapy rather than being the sole treatment.
C. Physical therapy is often the initial treatment for Erb's palsy, focusing on gentle stretching exercises, range of motion activities, and strengthening exercises to improve muscle function and joint mobility.
D. While Erb's palsy may improve over time for some infants, early intervention with physical therapy is generally recommended to optimize outcomes and prevent long- term complications.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is providing anticipatory guidance to a mother of a 5-month-old boy about introducing solid foods. Which statement by the mother indicates that effective teaching has occurred?

Correct Answer is C

Explanation

A neonate is diagnosed with Erb's palsy after birth. The parents are concerned about their neonate's limp arm. The nurse explains the neonate will be scheduled to receive what recommended treatment for this condition first?

Correct Answer is C

Explanation

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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?

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