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. Children with health issues may actually be at an increased risk of being bullied due to differences in appearance or ability.
B. Both boys and girls are bullied, but they may experience different types of bullying. Boys usually bully boys and use physical force more often, while girls may bully girls or boys and use verbal or relational aggression more often.
C. Children who bully are not necessarily those who are lonely or have difficulty in forming friendships. Some children who bully may have high self-esteem, popularity, or social power. They may bully to dominate, control, or impress others.
D. This statement may not accurately reflect the prevalence of fear among school children and does not address the developmental concern of bullying.
Correct Answer is ["C","D","E"]
Explanation
A. Providing praise when deserved is important for reinforcing positive behavior and fostering self-esteem.
B. Speaking to the child as an authority figure may create distance and hinder effective communication.
C. Talking face to face and being aware of body language can enhance communication and understanding between parents and adolescents.
D. Acknowledging uncertainty and not pretending to have all the answers can foster honesty and openness in communication.
E. Asking questions to understand the adolescent's perspective and feelings encourages dialogue and mutual understanding.
F. Admitting mistakes and modeling accountability is important for building trust and demonstrating humility in parent-adolescent relationships.
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