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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. While acknowledging the father's concerns is important, this response doesn't provide guidance on addressing potential depression in the son.
B. Offering to refer the son for evaluation with a therapist if mood issues are noticed is important and provides proactive support and guidance for addressing potential depression but screening children with a risk factor for depression from the age of 11 is the best choice.
C. While regular screening may be indicated for at-risk teens, waiting until age 14 may miss opportunities for early intervention in some cases.
D. Screening for depression is recommended for all children aged 11 and older, especially those who have a family history of depression or other risk factors. The nurse should inform the father that screening his son for depression is important and can help identify any signs or symptoms early. This is based on the recommendations of the American Academy of Pediatrics, which state that pediatric primary care providers should screen all children and adolescents for depression at least once a year, starting from age 11.
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.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.