Author Question: An infant's temperature is recorded at 36 C (96.8 F) during the morning assessment in the newborn ... (Read 31 times)

Lisaclaire · **on:** Jun 28, 2018

An infant's temperature is recorded at 36 C (96.8 F) during the morning assessment in the newborn nursery. Which priority action should the nurse implement?

a. Note the findings in the electronic health record (EHR).
b. Unwrap the infant and inspect for abnormalities.
c. Provide the infant with glucose water.
d. Make sure that the infant is wrapped securely with a blanket and recheck temperature in 15 minutes.

Question 2

In reviewing safety concerns for the newborn nursery, an ad hoc committee has been organized to discuss methods to prevent infant abduction. Which option can be used to facilitate improved outcomes related to this potential problem?

a. Allow only immediate adult family members to visitor the newborn nursery during unrestricted visiting hours.
b. Require identification with picture ID confirmation of all family members and/or staff who want to have contact with the newborn.
c. Make sure that all emergency exits are accessible to staff and clients on the unit.
d. Limit the number of visitors to two per client who can be on the unit during visiting hours to maintain security.

miss.ashley · **Reply #1 on:** Jun 28, 2018

Answer to Question 1

ANS: D
This temperature potentially indicates hypothermia, so the infant should be wrapped securely in a blanket and reassessed after that intervention. Findings should be documented in the EHR, but this is not the priority intervention. Unwrapping the infant would lead to further compromise and additional risk for the core temperature to drop. Feeding the infant with glucose water may eventually be used as an intervention if the infant shows additional signs of hypoglycemia, which may accompany hypothermia.

Answer to Question 2

ANS: B
Requiring appropriate identification is the best method of preventing possible infant abduction. Evidenced-based practice has indicated that potentially family and/or staff or someone representing themselves as such is more likely to attempt an infant abduction. The unit should be a closed or locked unit and require admittance to maintain security. Limiting the visitors to two per client may cause increased stress to the new family because they want to share this experience. Preventing siblings from visiting by only allowing immediate adult family members may prevent beginning sibling attachment and cause separation and stress anxiety to the mother and children.