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 B

Explanation

A. Puzzles are more related to cognitive skills than gross motor skills.
B. Participation in sports often involves various gross motor activities such as running, jumping, and throwing, making it a relevant question for assessing gross motor skills.
C. Playing instruments primarily involves fine motor skills rather than gross motor skills.
D. Constructing models may involve some fine motor skills but is not necessarily indicative of gross motor skills.

A. Funding for projects B. Adequate staffing C. Finding an audience D. Partnership development

Correct Answer is D

Explanation

A. While funding is important for sustaining health promotion activities, it may not be the key strategy for success.
B. Adequate staffing is necessary for program implementation but may not be the most critical factor for success.
C. Finding an audience is essential for targeted interventions but may not ensure the success of the program on its own.
D. Partnership development, especially with community organizations, healthcare providers, and governmental agencies, can enhance resources, reach, and sustainability of health promotion activities.

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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

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The nurse is assessing the gross motor skills of an 8-year-old boy. Which interview question would facilitate this assessment?

Correct Answer is B

Explanation

The nurse working in a community clinic attempts to establish a free vaccination program to refer low-income families. What is the key strategy for success when implementing a health promotion activity?

Correct Answer is D

Explanation

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