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 B
Explanation
A. Enriched bread may contain some calcium, but it's not as rich a source as other options.
B. White beans are a good source of calcium, which is important for bone health in preschoolers.
C. Fortified cereal may contain added calcium, but it may not be as naturally rich as other food sources.
D. While spinach contains calcium, it also contains oxalates, which can inhibit calcium absorption, making it a less effective source of dietary calcium.
Correct Answer is ["A","B","C"]
Explanation
A. Wanting friends to visit more than parents is more indicative of this stage, as they reflect the client's interest in social relationships.
B. Being very concerned with implications of laws or regulations demonstrates abstract thinking and consideration of complex societal issues, characteristic of middle formal operational thinking.
C. Wanting to make decisions about healthcare independently reflects increasing autonomy and ability to think abstractly.
D. Difficulty understanding implications of a diagnosis may indicate cognitive limitations rather than middle formal operational thinking.
E. Reporting occasional marijuana use may indicate behavior but does not necessarily reflect cognitive development according to Piaget's theory.
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.