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Chapter 34: Problem 537

A nursing assistant reports to a staff nurse that the neonate assigned to her care is crying and has axillary temperature of \(90^{\circ} \mathrm{F}\). Which is the appropriate action on the part of the staff nurse? A. Call a code B. Notify the physician C. Retake the temperature D. Place the infant in a warming unit

Short Answer

Expert verified
The best immediate action is to retake the temperature to confirm accuracy (Option C).

Step by step solution

01

Understand the Situation

A neonate (newborn) is crying and has an axillary (underarm) temperature of 90掳F. This is significantly below the normal range of around 97.7掳F to 99.5掳F for axillary temperature in neonates.
02

Identify the Critical Issue

The primary concern is the low temperature, which is termed hypothermia. Hypothermia in newborns can lead to serious health problems if not addressed promptly.
03

Evaluate the Options

Consider each of the provided options:A. Calling a code is reserved for life-threatening emergencies and is not the immediate appropriate response.B. Notifying the physician may be necessary, but first confirm the temperature reading.C. Retaking the temperature is a quick way to confirm if the initial reading was accurate.D. Placing the infant in a warming unit directly addresses the hypothermia.
04

Determine the Best Immediate Action

Given that the temperature reading is critical, the first step should be to confirm the accuracy of this temperature by retaking it.

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Key Concepts

These are the key concepts you need to understand to accurately answer the question.

Hypothermia in Newborns
Hypothermia in newborns is a condition where the baby's body temperature drops below the normal range, typically below 97.7掳F (36.5掳C). This is a serious health issue that requires immediate attention. Newborns are particularly susceptible to hypothermia because they have a larger body surface area relative to their weight, and their ability to regulate body temperature is not fully developed.
Signs of hypothermia in newborns include:
  • Cold skin
  • Lethargy
  • Poor feeding
  • Weak cry
If not treated promptly, hypothermia can lead to severe complications such as respiratory distress, metabolic problems, and even death. Immediate interventions are crucial to stabilize the baby's body temperature and ensure their well-being.
Temperature Measurement in Neonates
Accurately measuring a newborn's temperature is essential for ensuring their health and detecting any abnormalities like hypothermia. In neonates, the axillary (underarm) method is commonly used because it is safe and non-invasive.
The steps for measuring axillary temperature in neonates are:
  • Ensure the thermometer is clean and functional.
  • Place the thermometer in the newborn's underarm.
  • Hold the baby鈥檚 arm snugly against their body to keep the thermometer in place.
  • Wait until the thermometer beeps or indicates that the reading is complete.
Normal axillary temperature ranges from 97.7掳F to 99.5掳F (36.5掳C to 37.5掳C). If the reading is significantly lower, as in the case of a measurement of 90掳F, it indicates a critical condition that necessitates immediate action.
Immediate Nursing Actions
When a newborn is found to have a low temperature, immediate nursing actions are crucial to prevent further complications. The first step is to verify the accuracy of the initial temperature reading. Retake the temperature to confirm it.
Once hypothermia is confirmed, the following actions should be taken:
  • Place the neonate in a warming unit or an incubator to gradually raise their body temperature.
  • Ensure the newborn is dry and dressed in warm clothing or blankets.
  • Monitor the baby鈥檚 temperature closely and continuously.
  • Inform the physician immediately to get further instructions and be ready for additional interventions if required.
Acting promptly and correctly can help stabilize the baby's condition and minimize the risk of serious health complications.

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Most popular questions from this chapter

An industrial nurse responds to an emergency in the plant where a worker is burned. Which is the correct sequence of nursing actions? A. Eliminate the source of the burn, ensure airway patency, observe for and treat associated injuries, treat burn shock. B. Eliminate the source of the burn, ensue airway patency, cool the burn wound, apply topical antibiotic cream. C. Ensure airway patency, insert a nasogastric tube, insert a bladder catheter, stare IV fluid infusion. D. Treat burn shock, ensure airway patency, start IV antibiotics and put the client in reverse isolation.

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