A Nurse Is Assessing A Neonate Which Finding Suggests Hypothermia?
Asked by: Ms. Dr. Emma Richter B.Eng. | Last update: July 15, 2022star rating: 4.3/5 (11 ratings)
Temperature & Neutral Thermal Environment A temperature of ≤36.5oC is considered hypothermic and a medical review is required. Nursing interventions can include: An extra layer (clothing/blanket) should be added, and the temperature should be repeated hourly.
When performing an assessment of a neonate which assessment finding is most suggestive of hypothermia?
When performing an assessment on a neonate, which assessment finding is most suggestive of hypothermia? 1. Bradycardia. Hypothermic neonates become bradycardic proportional to the degree of core temperature.
Which of the following may occur as a result of cold stress to an infant quizlet?
The consequences of cold stress can be quite severe. As the body temperature decreases, the newborn becomes less active, lethargic, hypotonic, and weaker. All newborns are at risk for cold stress, particularly within the first 12 hours of life.
Which assessment signs if noted in the newborn infant would alert the nurse to the possibility of this respiratory distress syndrome?
Signs and Symptoms Grunting “ugh” sound with each breath. Changes in color of lips, fingers and toes. Widening (flaring) of the nostrils with each breath. Chest retractions - skin over the breastbone and ribs pulls in during breathing.
What are the 4 consequences of cold stress select all that apply?
Select all that apply. Rationale: Signs of cold stress include decreased skin temperature, increased respiratory rate with periods of apnea, bradycardia, mottling of skin, and lethargy.
NCLEX Sample Questions For Maternal And Child Health
22 related questions found
When performing a newborn assessment the nurse should measure the vital signs in the following sequence *?
Respirations, pulse, temperature - This sequence is least disturbing. Touching with the stethoscope and inserting the thermometer increases anxiety and elevates vital signs. 3.
What does the Ballard examination of a newborn infant assess?
The Dubowitz/Ballard Examination evaluates a baby's appearance, skin texture, motor function, and reflexes. The physical maturity part of the examination is done in the first 2 hours of birth. The neuromuscular maturity examination is completed within 24 hours after delivery.
Which of the following is a common cause of hypothermia in an infant?
Neonates are prone to rapid heat loss and consequent hypothermia because of a high surface area to volume ratio, which is even higher in low-birth-weight neonates. There are several mechanisms for heat loss: Radiant heat loss: Bare skin is exposed to an environment containing objects of cooler temperature.
What are the signs symptoms and effects of cold stress in a newborn?
Cold stress or mild hypothermia: 36.0 C to 36.4 C (96.8 F - 97.5 F) An accurate axillary (armpit) or rectal temperature below 36.4 C (97.5 F) A weak cry. Low energy level. Lethargic. Reddish and cold skin. Cool feeling of extremities and abdomen. Poor feeding. Hypoglycemia (low blood sugar)..
What is cold stress in a newborn?
Cold stress is a cascade of physiological events caused by the infant's use of chemically mediated thermogenesis in attempt to increase core temperature.
What effect does hypothermia have on the newborn?
The consequences of increased metabolism during hypothermia include hypoglycemia, hypoxia and metabolic acidosis. Behaviorally, cold infants will initially become more agitated, sleep less and lie in a flexed posture to reduce skin exposure to the air.
Which finding would alert the nurse to suspect that a newborn is experiencing respiratory distress?
Which finding would alert the nurse to suspect that a newborn is experiencing respiratory distress? Chest movements should be symmetrical. Typical newborn respirations range from 30 to 60 breaths per minute.
What does respiratory distress look like in infants?
Nasal flaring - Check to see if nostrils widen when breathing in. (“Ugh” sound), wheezing or like mucus is in the throat. Clammy skin – Feel your child's skin to see if it is cool but also sweaty. The head may be sweaty while the skin feels cool or clammy.
What is a result of hypothermia in the newborn quizlet?
In hypothermia, the basal metabolic rate (BMR) is increased in an attempt to. compensate, thus requiring more glucose. You just studied 11 terms! 1/11.
What is a consequence of hypothermia in a newborn quizlet?
Apnea, cyanosis, respiratory distress, and increased oxygen demand are all consequences of hypothermia. An infant is suffering from neonatal abstinence syndrome.
What are the symptoms of hypothermia?
What are the signs and symptoms of hypothermia? Shivering. Exhaustion or feeling very tired. Confusion. Fumbling hands. Memory loss. Slurred speech. Drowsiness. .
What is the normal heart rate of a neonate?
Normal Results For resting heart rate: Newborns 0 to 1 month old: 70 to 190 beats per minute. Infants 1 to 11 months old: 80 to 160 beats per minute. Children 1 to 2 years old: 80 to 130 beats per minute.
What are normal respirations for a newborn?
Tachypnea is the most common presentation in newborns with respiratory distress. A normal respiratory rate is 40 to 60 respirations per minute. Other signs may include nasal flaring, grunting, intercostal or subcostal retractions, and cyanosis.
What is the highest priority in the newborn assessment?
Respiratory Evaluation With every newborn contact, respiratory evaluation is necessary because this is the highest priority in newborn care. The Silverman and Andersen index can assess respiratory distress and its varying degrees. .
What does the New Ballard score assess?
The Ballard score is commonly used to determine gestational age. Here's how it works: Scores are given for 6 physical and 6 nerve and muscle development (neuromuscular) signs of maturity. The scores for each may range from -1 to 5.
When do you use the Ballard score?
. The Ballard score is based on the neonate's physical and neuromuscular maturity and can be used up to 4 days after birth (in practice, the Ballard score is usually used in the first 24 hours). The neuromuscular components are more consistent over time because the physical components mature quickly after birth.
What is the difference between Dubowitz and Ballard score?
The Ballard Method is different from the Dubowitz in that the physical exam and the neuromuscular exam have each been shortened to meet six criteria (Ballard et al, 95). The scores of each exam are added together to determine the appropriate maturity rating, which is typically accurate within a two week range.
What are the five stages of hypothermia?
Treating Hypothermia HT I: Mild Hypothermia, 35-32 degrees. Normal or near normal consciousness, shivering. HT II: Moderate Hypothermia, 32-28 degrees. Shivering stops, consciousness becomes impaired. HT III: Severe Hypothermia, 24-28 degrees. HT IV: Apparent Death, 15-24 degrees. HT V: Death from irreversible hypothermia. .
What are symptoms of hypothermia and how do you treat it?
Signs and symptoms of hypothermia include: Shivering. Slurred speech or mumbling. Slow, shallow breathing. Weak pulse. Clumsiness or lack of coordination. Drowsiness or very low energy. Confusion or memory loss. Loss of consciousness. .
What to do if a baby has hypothermia?
What to do If you suspect a baby has hypothermia, take them to a warm room and dress them in warm clothes. You can also wrap them in a blanket and hold them close to you to help to warm them up. Call 999 or 112 for emergency help. .
How do you control hypothermia in neonates?
7-16 How do you treat hypothermia? Warm the infant in a closed incubator, overhead radiant warmer or warm room. Skin-to-skin care is a very effective method of warming a cold infant. Provide energy while the infant is being warmed. Provide oxygen. Give 4% sodium bicarbonate. Observations. Antibiotics. .
How does hypothermia cause hypoglycemia in neonates?
When the baby gets cold he uses up more glycogen to keep warm. Then he must utilize his glucose stores to keep warm, then the blood sugar drops and they become hypothermic along with hypoglycemic.
