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.
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Related Questions
Correct Answer is C
Explanation
A. Stimulation methods may be used to engage the child's senses, but they are not primarily focused on keeping the child safe during a procedure like a lumbar puncture.
B. Therapeutic hugging can provide comfort and emotional support but may not directly address the safety needs of the child during the procedure.
C. Distraction methods, such as providing toys, games, or music, help divert the child's attention away from the procedure, reducing anxiety and promoting a sense of safety.
D. Therapeutic touch can be comforting but may not specifically address safety concerns during the procedure.
Correct Answer is A
Explanation
A. Amblyopia, often referred to as "lazy eye," is reduced vision in one eye due to abnormal visual development during early childhood.
B. Malalignment of the eyes typically refers to strabismus, not amblyopia.
C. Refractive errors such as myopia or hyperopia can cause visual impairment but are not specifically related to amblyopia.
D. Clouding of the lens of the eye is more commonly associated with conditions like cataracts, not amblyopia.
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