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","C","D","E"]
Explanation
A. Hyperthermia is not typically associated with an increased risk of necrotizing enterocolitis.
B. Low Apgar scores indicate that the baby had difficulty adapting to life outside the womb and may have suffered from hypoxia or acidosis.
C. Preterm birth is a significant risk factor for necrotizing enterocolitis.
D. Respiratory distress syndrome is associated with prematurity and is a risk factor for necrotizing enterocolitis.
E. Exchange transfusion, a procedure often performed in neonates with severe jaundice or anemia, is associated with an increased risk of necrotizing enterocolitis.
F. Hyperglycemia is not typically associated with an increased risk of necrotizing enterocolitis.
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.
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