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. Toddlers are typically not yet focused on peer approval as a developmental task.
B. While safety and security are important for toddlers, they are not the primary focus driving the behavior described.
C. Toddlers are asserting their need for independence and control over their environment, leading to behaviors such as tantrums when limits are set.
D. Love and belonging are important for all ages but are not the primary focus driving the behavior described.

A. Before answering questions, find out what the child thinks about the subject. B. Expand upon the topic when answering questions to prevent further confusion. C. Provide a less than honest response to shelter the child from knowledge that is too advanced. D. Be prepared to thoroughly cover a topic before the child asks about it.

Correct Answer is A

Explanation

A. Before answering questions, it's important to understand what the child already knows or thinks about the subject to provide developmentally appropriate information.
B. Expanding upon the topic when answering questions may overwhelm the child with too much information and may not be developmentally appropriate.
C. Providing a less than honest response may undermine trust between the parent and child and may not adequately address the child's curiosity or concerns.
D. Waiting until the child asks about a topic may miss opportunities for proactive, age-appropriate education and guidance.

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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

The nurse observing toddlers in a daycare center notes that they may be happy and pleasant one moment and overreact to limit setting the next minute by throwing a tantrum. What is the focus of the toddler's developmental task that is driving this behavior?

Correct Answer is C

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Correct Answer is A

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