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","C","D","E","F"]

Explanation

A. Past medical history is important but may not directly address current psychosocial concerns related to the child's asthma.
B. Transportation to healthcare facilities can be a significant psychosocial issue, as it may impact access to care and treatment adherence.
C. Assessing health maintenance needs can uncover barriers to care and support required for managing the chronic illness.
D. The nurse should discuss with the child and the family the goals and expectations for the child's asthma control and quality of life. The nurse should also inform them about any new or alternative therapies that may be available or suitable for the child.
E. The school's response to the chronic illness can affect the child's social and emotional well-being.
F. Health insurance coverage may impact the child's access to necessary healthcare services and medications, influencing their psychosocial experiences.

A. Letting him choose juice or soda to take pills B. Seeking the teenager's input on all decisions C. Avoiding undue criticism of noncompliance D. Discussing the benefits of chemotherapy with him

Correct Answer is A

Explanation

A. This technique might be appropriate for younger children, but not for teenagers who want more autonomy and respect. Letting him choose juice or soda might make him feel like he is being treated like a child, and not as a partner in his own care.
B. Seeking the teenager's input on decisions promotes autonomy and empowerment, which can be effective in adolescent healthcare.
C. Avoiding undue criticism of noncompliance is important for maintaining a supportive and trustful nurse-patient relationship, especially with adolescents.
D. The nurse should also discuss the benefits of chemotherapy with him, such as how it can kill cancer cells, shrink tumors, and improve his chances of survival. The nurse should explain the rationale and goals of chemotherapy in a clear and honest way, and answer any questions or concerns the teenager might have. By doing so, the nurse can help him understand the importance of adhering to the treatment plan, and motivate him to cope with the challenges.

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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

Naxlex Comprehensive Predictor Exams

The nurse is conducting a psychosocial assessment of a child with asthma brought to the healthcare provider's office for a check-up Which psychosocial issues may be assessed? Select all that apply.

Correct Answer is ["B","C","D","E","F"]

Explanation

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Correct Answer is A

Explanation

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