Thermoregulation
A 55-year-old widowed patient was in a motor vehicle accident and is admitted to a surgical unit after repair of a fractured left arm and left leg. She also has a laceration on her forehead. An intravenous (IV) line is infusing in the right antecubital fossa, and pneumatic compression stockings are on the right lower leg. She is receiving oxygen via a simple face mask. What sites do you instruct the nursing assistant to use for obtaining the patient's temperature? a. Tympanic membrane b. Right axillae c. Oral d. Temporal artery
ANS: B All others are affected by facial surgery and oxygen mask.
Which of the following patients is most at risk for tachycardia? a. A healthy professional tennis player b. A patient admitted with hypothermia c. A patient with a fever of 39.4° C (103° F) d. A 90-year-old male taking beta blockers
ANS: C Patients with a fever have a high heart rate. A healthy athlete has a low heart rate because of conditioning. Hypothermia slows the heart. Beta-blockers reduce heart rate.
A patient has been hospitalized for the past 48 hours with a fever of unknown origin. His medical record indicates tympanic temperatures of: 38.7° C (101.6° F) (0400) 36.6° C (97.9° F) (0800) 36.9° C (98.4° F) (1200) 37.6° C (99.6° F) (1600) 38.3° C (100.9° F) (2000). How would you describe this pattern of temperature measurements? a. Usual range of circadian rhythm measurements b. Sustained fever pattern c. Intermittent fever pattern d. Resolving fever pattern
ANS: C The pattern returns to acceptable levels at least once in 24 hours interspersed with fever spikes.
The nurse has just administered ibuprofen (Motrin) to a child with a temperature of 38.8° C (102° F). The nurse should also take which action? a. Withhold oral fluids for 8 hours. b. Sponge the child with cold water. c. Plan to administer salicylate (aspirin) in 4 hours. d. Remove excess clothing and blankets from the child.
ANS: D After administering ibuprofen, excess clothing and blankets should be removed. The child can be sponged with tepid water, but not cold water because the cold water can cause shivering, which increases metabolic requirements above those already caused by the fever. Aspirin is not administered to a child with fever because of the risk of Reye's syndrome. Fluids should be encouraged to prevent dehydration, so oral fluids should not be withheld.
In comparison with the term infant, the preterm infant has a. Few blood vessels visible though the skin b. More subcutaneous fat c. Well-developed flexor muscles d. Greater surface area in proportion to weight
ANS: D Preterm infants have greater surface area in proportion to their weight. The others are indications of a more mature infant.
A priority nursing intervention for a patient with hyperthermia would be a. Initiating seizure precautions. b. Limiting oral intake. c. Providing a blanket. d. Removing excess clothing.
ANS: D The priority nursing intervention would be removal of excess clothing. Seizures may occur because of a high body temperature, but seizure precautions should not be the first intervention. Oral intake, especially of fluids, should not be limited for a patient with hyperthermia, because of the dangers of dehydration. Blanketing, like clothing, should be removed.
The nurse is caring for a patient who has an elevated temperature. The nurse understands that a. Fever and hyperthermia are the same thing. b. Hyperthermia occurs when the body cannot reduce heat loss. c. Hyperthermia is an upward shift in the set point. d. Hyperthermia occurs when the body cannot reduce heat production.
ANS: D Fever and hyperthermia are not the same things. An elevated body temperature related to the body's inability to promote heat loss or reduce heat production is hyperthermia. Fever is an upward shift in the set point. Hyperthermia is not a shift in the set point.
An 18-year-old male who fell through the ice on a pond near his farm was admitted to the ED with somnolence. Vital signs are BP 82 mm Hg systolic with Doppler, respirations 9/min, and core temperature of 90° F (32.2° C). The nurse should anticipate which intervention? a. Active core rewarming b. Immersion in a hot bath c. Rehydration and massage d. Passive external rewarming
ANS: A Active internal or core rewarming is used for moderate to severe hypothermia and involves the application of heat directly to the core. Immersion in a hot bath, rehydration, and massage are not appropriate interventions in the treatment of severe hypothermia. Passive rewarming is used in mild hypothermia.
Nurses can prevent evaporative heat loss in the newborn by a. Drying the baby after birth and wrapping the baby in a dry blanket b. Keeping the baby out of drafts and away from air conditioners c. Placing the baby away from the outside wall and the windows d. Warming the stethoscope and nurse's hands before touching the baby
ANS: A Because the infant is wet with amniotic fluid and blood, heat loss by evaporation occurs quickly. Heat loss by convection occurs when drafts come from open doors and air currents created by people moving around. If the heat loss is caused by placing the baby near cold surfaces or equipment, it is termed a radiation heat loss. Conduction heat loss occurs when the baby comes in contact with cold objects or surfaces.
The most important reason to protect the preterm infant from cold stress is that a. It could make respiratory distress syndrome worse b. Shivering to produce heat may use up too many calories c. A low temperature may make the infant less able to digest nutrients d. Cold decreases circulation to the extremities
ANS: A Cold stress may interfere with the production of surfactant, making respiratory distress syndrome worse. Preterm infants do not shiver to produce heat. Cold stress does interfere with ability to eat, but not with the ability to digest the nutrients. Decrease circulation is not the top priority in caring for an infant with cold stress.
A patient with hypothermia is brought to the emergency department. The nurse should explain to the family members that treatment will include a. Core rewarming with warm fluids. b. Ambulation to increase metabolism. c. Frequent oral temperature assessment. d. Gastric tube feedings to increase fluids.
ANS: A Core rewarming with heated oxygen and administration of warmed oral or intravenous fluids is the preferred method of treatment. The patient would be too weak to ambulate. Oral temperatures are not the most accurate assessment of core temperature because of environmental influences. Warmed oral feedings are advised; gastric gavage is unnecessary.
Which nursing action is designed to avoid unnecessary heat loss in the newborn? a. Place a blanket over the scale before weighing the infant. b. Maintain room temperature at 70° F. c. Undress the infant completely for assessments so they can be finished quickly. d. Take the rectal temperature every hour to detect early changes.
ANS: A Padding the scale prevents heat loss from the infant to a cold surface by conduction. Room temperature should be appropriate to prevent heat loss from convection. Also, if the room is warm enough, radiation will assist in maintaining body heat. Undressing the infant completely will expose the child to cooler room temperatures and cause a drop in body temperature due to convection. Hourly assessments are not necessary for a normal newborn with a stable temperature.
A homeless person is brought to the emergency department after prolonged exposure to cold weather. The nurse would assess the patient for manifestations of hypothermia, including a. Stupor. b. Erythema. c. Increased anxiety. d. Rapid respirations.
ANS: A Stupor may occur with hypothermia because of slowed cerebral metabolic processes. Pallor, not erythema, would be present as a result of peripheral vasoconstriction. Drowsiness occurs; the patient would be unable to focus on anxiety-producing aspects of the situation. Respirations would be decreased.
Of the following patients, which one is the best candidate to have his temperature taken orally? a. A 27-year-old postoperative patient with an elevated temperature b. A teenage boy who has just returned from outside "for a smoke" c. An 87-year-old confused male suspected of hypothermia d. A 20-year-old male with a history of epilepsy
ANS: A An elevated temperature needs to be evaluated, and there is no contraindication in this patient. Ingestion of hot/cold fluids or foods, smoking, or receiving oxygen by mask/cannula can require delays in taking oral temperature. Oral temperatures are not taken for patients who have had oral surgery, trauma, history of epilepsy, or shaking chills, nor for infants, small children, or confused patients.
The patient is restless with a temperature of 102.2° F (39° C). One of the first things the nurse should do is a. Place the patient on oxygen. b. Restrict fluid intake. c. Increase patient activity. d. Increase patient's metabolic rate.
ANS: A During a fever, cellular metabolism increases and oxygen consumption rises. Myocardial hypoxia produces angina. Cerebral hypoxia produces confusion. Interventions during a fever include oxygen therapy. Dehydration is a serious problem through increased respiration and diaphoresis. The patient is at risk for fluid volume deficit. Fluids should not be restricted. Increasing activity would increase the metabolic rate further, which would not be advisable
The posterior hypothalamus helps control temperature by a. Causing vasoconstriction. b. Shunting blood to the skin and extremities. c. Increasing sweat production. d. Causing vasodilation
ANS: A If the posterior hypothalamus senses that the body's temperature is lower than the set point, the body initiates heat conservation mechanisms. Vasoconstriction of blood vessels reduces blood flow to the skin and extremities. The anterior hypothalamus controls heat loss by inducing sweating, vasodilation of blood vessels, and inhibition of heat production
What clinical indicator will the nurse most likely identify when assessing a patient with pyrexia? a. Dyspnea. b. Precordial pain. c. Increased pulse rate. d. Elevated blood pressure.
ANS: C The pulse rate increases to meet increased tissue demands for oxygen in the febrile state. Fever may increase but does not cause difficulty in breathing. Pain is not related to fever. Blood pressure is not necessarily elevated in fever.
When heat loss mechanisms of the body are unable to keep pace with excess heat production, the result is known as a. Pyrexia. b. The plateau phase. c. The set point. d. Becoming afebrile.
ANS: A Pyrexia, or fever, occurs because heat loss mechanisms are unable to keep pace with excess heat production, resulting in an abnormal rise in body temperature. The set point is the temperature point determined by the hypothalamus. When pyrogens trigger immune system responses, the hypothalamus reacts to raise the set point, and the body produces and conserves heat. During the plateau phase, chills subside and the person feels warm and dry as heat production and loss equilibrate at the new level. When the fever "breaks," the patient becomes afebrile.
A 56-year-old patient with diabetes admitted for community acquired pneumonia has a temperature of 38.2°C (100.8°F) via the temporal artery. Which additional assessment data are needed in planning interventions for the patient's infection? (Select all that apply.) a. Heart rate b. Presence of diaphoresis c. Smoking history d. Respiratory rate e. Recent bowel movement f. Blood pressure in right arm g. Patient's normal temperature h. Blood pressure in distal extremity
ANS: A, B, D, G You need to determine the patient's usual temperature to evaluate the degree of temperature elevation. Heart rate and respiratory rate increase with temperature. The presence of diaphoresis may contribute to fluid volume deficit from hyperthermia.
The patient has been part of a community emergency response team (CERT) for a tropical storm in Dallas where it has been 100° F (37.7° C) or more for the last 2 weeks. With assessment, the nurse finds hypotension, body temperature of 104° F (40° C), dry and ashen skin, and neurologic symptoms. What treatments should the National Disaster Medical System (NDMS) nurse anticipate (select all that apply)? a. Administer 100% O2. b. Immerse in an ice bath. c. Administer cool IV fluids. d. Cover the patient to prevent chilling. e. Administer acetaminophen (Tylenol).
ANS: A, C The patient is experiencing heatstroke. Treatment focuses first on stabilizing the patient's ABC and rapidly reducing the core temperature. Administration of 100% O2 compensates for the patient's hypermetabolic state. Cooling the body with IV fluids is effective. Immersion in an ice bath will cause shivers that increase core temperature, so a cool water bath should be used for conductive cooling. Removing the clothing, covering the patient with wet sheets, and placing the patient in front of a fan will cause evaporative cooling. Excessive covers will not be used. Acetaminophen will not be effective because the increase in temperature is not related to infection.
The client being treated for hyperthyroidism calls the home health nurse and mentions that his heart rate is slower than usual. What is the nurse's best response? a. Advises the client to go to a calming environment b. Asks whether the client has increased cold sensitivity or weight gain c. Instructs the client to see his health care provider immediately d. Tells the client to check the pulse again and call back later
ANS: B Increased sensitivity to cold and weight gain are symptoms of hypothyroidism, indicating an overcorrection of the medication. The client must be assessed further because he may require a lower dose of medication. A calming environment will not have any effect on the client's heart rate. he client will want to notify the health care provider about the change in heart rate. If other symptoms such as chest pain, shortness of breath, or confusion accompany the slower heart rate, then the client should see the health care provider immediately. If the client was concerned enough to call because his heart rate was slower than usual, the nurse needs to stay on the phone with the client while he re-checks his pulse. This time could also be spent providing education about normal ranges for that client.
A child is about to be admitted to the pediatric intensive care unit (PICU) after surgery for removal of a tumor in the hypothalamic region of the brain. The nurse manager should intervene immediately when the child's nurse a. Places a hypothermia blanket at the bedside. b. Adjusts the bed to the Trendelenburg position. c. Obtains electronic equipment for monitoring the vital signs. d. Secures a pump to administer the ordered intravenous fluids.
ANS: B It is not safe to put the bed in the Trendelenburg position, because raising the foot increases blood flow to the brain, thereby increasing intracranial pressure. Temperature elevations may occur after a craniotomy because of stimulation of the hypothalamus. A hypothermic blanket should be ready if the temperature becomes precipitously elevated. Monitoring vital signs is a critical component of postoperative care. Intravenous infusions must be regulated precisely to minimize the possibility of cerebral edema.
The patient has a temperature of 105.2° F. The nurse is attempting to lower his temperature by providing tepid sponge baths and placing cool compresses in strategic body locations. The nurse is attempting to lower the patient's temperature through the use of a. Radiation. b. Conduction. c. Convection. d. Evaporation
ANS: B Applying an ice pack or bathing a patient with a cool cloth increases conductive heat loss. Radiation is the transfer of heat from the surface of one object to the surface of another without direct contact between the two. Evaporation is the transfer of heat energy when a liquid is changed to a gas. Convection is the transfer of heat away from the body by air movement.
The nurse is working the night shift on a surgical unit and is making 4 AM rounds. She notices that the patient's temperature is 96.8° F (36° C), whereas at 4 PM the preceding day, it was 98.6° F (37° C). What should the nurse do? a. Call the physician immediately to report a possible infection. b. Realize that this is a normal temperature variation. c. Provide another blanket to conserve body temperature. d. Provide medication to lower the temperature further
ANS: B Body temperature normally changes 0.5° C to 1° C (0.9° F to 1.8° F) during a 24-hour period and is usually lowest between 1:00 and 4:00 AM, making this variation normal for the time of day. Unless the patient is complaining of being cold, there is no physiological need for providing an extra blanket or medication to lower the body temperature further. There is also no need to call a physician to report a normal temperature variation.
After taking the patient's temperature, the nurse documents the value and the route used to obtain the reading. Why is this done? a. Temperatures are the same regardless of the route used. b. Temperatures vary depending on the route used. c. Temperatures are cooler when taken rectally than when taken orally. d. Axillary temperatures are higher than oral temperatures.
ANS: B Temperatures obtained vary depending on the site used. Rectal temperatures are usually 0.5 C (0.9 F) higher than oral temperatures, and axillary temperatures are usually 0 C (0.9 F) lower than oral temperatures.
The nurse is caring for an elderly patient and notes that his temperature is 96.8° F (36° C). She understands that this patient is a. Suffering from hypothermia. b. Expressing a normal temperature. c. Hyperthermic relative to his age. d. Demonstrating the increased metabolism that accompanies aging.
ANS: B The average body temperature of older adults is approximately 96.8° F (36° C). This is not hypothermia or hyperthermia. Older adults have poor vasomotor control, reduced amounts of subcutaneous tissue, and reduced metabolism. The end result is lowered body temperature
When temperature assessment is required, which of the following cannot be delegated to nursing assistive personnel? a. Temperature measurement b. Assessment of changes in body temperature c. Selection of appropriate route and device d. Consideration of factors that falsely raise temperature
ANS: B The skill of temperature measurement can be delegated. The nurse is responsible for assessing changes in body temperature. The nurse instructs nursing assistive personnel to select the appropriate route and device to measure temperature and to consider specific factors that falsely raise or lower temperature.
The patient requires routine temperature assessment but is confused and easily agitated and has a history of seizures. The nurse's best option would be to take his temperature a. Orally. b. Tympanically. c. Rectally. d. By the axillary method.
ANS: B The tympanic route is easily accessible, requires minimal patient repositioning, and often can be used without disturbing the patient. It also has a very rapid measurement time. Oral temperatures require patient cooperation and are not recommended for patients with a history of epilepsy. Rectal temperatures require positioning and may increase patient agitation. Axillary temperatures need long measurement times and continuous positioning by the nurse. The patient's agitation state may not allow for long periods of attention.
Heat loss by convection occurs when a newborn is a. Placed on a cold circumcision board b. Given a bath c. Placed in a drafty area of the room d. Wrapped in cool blankets
ANS: C Convection occurs when infants are exposed to cold air currents. A cold circumcision board and cool blankets would cause heat loss by conduction, while heat loss due to a bath would be due to evaporation.
The nurse assisted with the delivery of a newborn. Which nursing action is most effective in preventing heat loss by evaporation? a. Warming the crib pad b. Closing the doors to the room c. Drying the infant with a warm blanket d. Turning on the overhead radiant warmer
ANS: C Evaporation of moisture from a wet body dissipates heat along with the moisture. Keeping the newborn dry by drying the wet newborn at birth prevents hypothermia via evaporation. Hypothermia caused by conduction occurs when the newborn is on a cold surface, such as a cold pad or mattress, and heat from the newborn's body is transferred to the colder object (direct contact). Warming the crib pad assists in preventing hypothermia by conduction. Convection occurs as air moves across the newborn's skin from an open door and heat is transferred to the air. Radiation occurs when heat from the newborn radiates to a colder surface (indirect contact).
A client with a neurological problem is experiencing hyperthermia. Which measure would be least appropriate for the nurse to use in trying to lower the client's body temperature? a. Giving tepid sponge baths. b. Applying a hypothermia blanket. c. Placing ice packs in the axilla and groin areas. d. Administering acetaminophen (Tylenol) per protocol.
ANS: C Ice packs are not used because they could cause shivering, which increases cellular oxygen demands, with the potential for increased intracranial pressure
What is a result of hypothermia in the newborn? a. Shivering to generate heat b. Decreased oxygen demands c. Increased glucose demands d. Decreased metabolic rate
ANS: C In hypothermia, the basal metabolic rate (BMR) is increased in an attempt to compensate, thus requiring more glucose. Shivering is not an effective method of heat production for newborns. Oxygen demands increase with hypothermia. The metabolic rate increases with hypothermia.
The nurse thoroughly dries the infant immediately after birth primarily to a. Stimulate crying and lung expansion. b. Remove maternal blood from the skin surface. c. Reduce heat loss from evaporation. d. Increase blood supply to the hands and feet.
ANS: C Infants are wet with amniotic fluid and blood at birth,which accelerates evaporative heat loss. Rubbing the infant does stimulate crying, but it is not the main reason for drying the infant. Drying the infant after birth does not remove all of the maternal blood.
The client is being discharged with hypothyroidism. Which environmental change may the client experience in the home? a. Frequent home care b. Handrails in the bath c. Increased thermostat setting d. Strict infection control measures
ANS: C Manifestations of hypothyroidism include cold intolerance. Increased thermostat settings or additional clothing may be necessary. A client with a diagnosis of hypothyroidism can be safely managed at home with adequate discharge teaching regarding medications and instructions on when to notify the health care provider or home health nurse. In general, hypothyroidism does not cause mobility issues. Activity intolerance and fatigue may however be an issue. A client with hypothyroidism is not immune compromised or contagious. No environmental changes need to be made to the home.
As a result of large body surface in relation to weight, the preterm infant is at high risk for heat loss and cold stress. By understanding the four mechanisms of heat transfer (convection, conduction, radiation, and evaporation), the nurse can create an environment for the infant that prevents temperature instability. While evaluating the plan that has been implemented, the nurse knows that the infant is experiencing cold stress when he or she exhibits: a. Decreased respiratory rate. b. Bradycardia followed by an increased heart rate. c. Mottled skin with acrocyanosis. d. Increased physical activity.
ANS: C The infant has minimal to no fat stores. During times of cold stress the skin will become mottled, and acrocyanosis will develop, progressing to cyanosis. Even if the infant is being cared for on a radiant warmer or in an isolette, the nurse's role is to observe the infant frequently to prevent heat loss and respond quickly if signs and symptoms occur. The respiratory rate increases followed by periods of apnea. The infant initially tries to conserve heat and burns more calories, after which the metabolic system goes into overdrive. In the preterm infant experiencing heat loss, the heart rate initially increases, followed by periods of bradycardia. In the term infant, the natural response to heat loss is increased physical activity. However, in a term infant experiencing respiratory distress or in a preterm infant, physical activity is decreased.
Of the following mechanisms of heat loss by the body, identify the mechanism that transfers heat away by using air movement? a. Radiation b. Conduction c. Convection d. Evaporation
ANS: C Convection is the transfer of heat away from the body by air movement. Conduction is the transfer of heat from one object to another with direct contact. Radiation is the transfer of heat from the surface of one object to the surface of another without direct contact between the two. Evaporation is the transfer of heat energy when a liquid is changed to a gas.
Which statement is true of the ovulation phase? a. Progesterone levels are below normal. b. Body temperature is below baseline levels. c. Body temperature is at previous baseline levels or higher. d. Intense body heat and sweating occur.
ANS: C Progesterone levels rise and fall cyclically during the menstrual cycle. When progesterone levels are low, the body temperature is a few tenths of a degree below the baseline. The lower temperature persists until ovulation occurs. During ovulation, greater amounts of progesterone enter the circulatory system and raise the body temperature to previous baseline levels or higher. These temperature variations help to predict a woman's most fertile time to achieve pregnancy. Women who undergo menopause (cessation of menstruation) often experience periods of intense body heat and sweating lasting from 30 seconds to 5 minutes (hot flashes)
The patient is being admitted to the emergency department following a motor vehicle accident. His jaw is broken, and he has several broken teeth. He is ashen, and his skin is cool and diaphoretic. To obtain an accurate temperature, the nurse uses which of the following routes? a. Oral b. Axillary c. Rectal d. Temporal
ANS: C The rectal route is argued to be more reliable when oral temperature cannot be obtained. Oral temperatures are not used for patients who have had oral surgery, trauma, history of epilepsy, or shaking chills. Axillary temperature is affected by exposure to the environment, including time to place the thermometer. It also requires a long measurement time. Temporal artery temperature is affected by skin moisture such as diaphoresis or sweating
The nurse is caring for a patient who has a temperature reading of 100.4° F (38° C). His last two temperature readings were 98.6° F (37° C) and 96.8° F (36° C). The nurse should a. Call the physician and anticipate an order to treat the fever. b. Assume that the patient has an infection and order blood cultures. c. Wait an hour and recheck the patient's temperature. d. Be aware that temperatures this high are harmful and affect patient safety.
ANS: C Waiting an hour and rechecking the patient's temperature would be the most appropriate action in this case. A fever usually is not harmful if it stays below 102.2° F (39° C), and a single temperature reading does not always indicate a fever. In addition to physical signs and symptoms of infection, a fever determination is based on several temperature readings at different times of the day compared with the usual value for that person at that time. Mild temperature elevations enhance the body's immune system by stimulating white blood cell production. Usually, staff nurses do not order blood cultures, and nurses should base actions on knowledge, not on assumptions.
Of the following sites, which are used for obtaining a core temperature? (Select all that apply.) a. Oral b. Rectal c. Tympanic d. Axillary e. Pulmonary artery
ANS: C, E Intensive care units use the core temperatures of the pulmonary artery, esophagus, and urinary bladder. Because the tympanic membrane shares the same arterial blood supply as the hypothalamus, the tympanic temperature is a core temperature. Oral, rectal, axillary, and skin temperature sites rely on effective blood circulation at the measurement site.
A patient has been admitted for a cerebrovascular accident (stroke). She cannot move her right arm, and she has a right-sided facial droop. She is able to eat with her dentures in place and swallow safely. The nursing assistive personnel (NAP) reports to you that the patient will not keep the oral thermometer probe in her mouth. What direction do you provide to the NAP? a. Direct the NAP to hold the thermometer in place with her gloved hand b. Direct the NAP to switch the thermometer probe to the left sublingual pocket c. Direct the NAP to obtain a right tympanic temperature d. Direct the NAP to use a temporal artery thermometer from right to left
ANS: D A temporal artery temperature verifies the forehead temperature in back of the left ear, which is the side not affected by the altered blood flow related to the stroke. Holding the thermometer or switching locations will not help the patient close her mouth during temperature assessment. The patient's right side has vascular changes related to the stroke.
While assessing the rectal temperature of a patient, the nurse slides a plastic disposable probe cover over the thermometer probe stem until the cover locks in place. What is the reason behind this intervention? a. Lubricating rectal mucosa during insertion b. Maintaining standard precautions when exposed c. Ensuring adequate exposure against blood vessels d. Preventing transmission of microorganisms between patients
ANS: D Sliding a disposable plastic probe cover over the thermometer probe stem will prevent the transmission of microorganisms between patients. Squeezing a liberal portion of lubricant on the tissue helps lubricate the rectal mucosa and minimizes trauma. Application of clean gloves between cleaning the anal region and measuring rectal temperature is important to maintain standard precautions. Inserting the thermometer probe gently into the anus in a direction of umbilicus 2.5 to 3.5 cm helps ensure adequate exposure against blood vessels in the rectal wall.
The postpartum nurse is taking the vital signs of a client who delivered a healthy newborn 4 hours ago. The nurse notes that the client's temperature is 100.2° F. What is the priority nursing action? a. Document the findings. b. Retake the temperature in 15 minutes. c. Notify the health care provider (HCP). d. Increase hydration by encouraging oral fluids.
ANS: D The mother's temperature may be taken every 4 hours while she is awake. Temperatures up to 100.4 (38 C) in the first 24 hours after birth are often related to the dehydrating effects of labor. The most appropriate action is to increase hydration by encouraging oral fluids, which should bring the temperature to a normal reading. Although the nurse would document the findings, the most appropriate action would be to increase the hydration.
The nurse admitting a patient to the emergency room on a cold winter night would suspect hypothermia when the patient demonstrates a. Increased respirations. b. Rapid pulse rate. c. Red, sweaty skin. d. Slow capillary refill.
ANS: D With hypothermia, there is slow capillary refill. There is an increased respiration rate with hyperthermia. The heart rate increases with hyperthermia. The skin is usually pale or cyanotic with hypothermia.
When focusing on temperature regulation of newborns and infants, the nurse understands that a. Temperatures are basically the same for infants and older adults. b. Infants have well-developed temperature-regulating mechanisms. c. The normal temperature range gradually increases as the person ages. d. Newborns need to wear a cap to prevent heat loss.
ANS: D A newborn loses up to 30% of body heat through the head and therefore needs to wear a cap to prevent heat loss. Temperature control mechanisms in newborns are immature and respond drastically to changes in the environment. The normal temperature range gradually drops as individuals approach older adulthood.
When assessing the temperature of newborns and children, the nurse decides to utilize a temporal artery thermometer. Why is this preferable to methods used for adults? a. It is accurate even when the forehead is covered with hair. b. It is not affected by skin moisture. c. It reflects rapid changes in radiant temperature. d. There is no risk of injury to patient or nurse
ANS: D The temporal artery thermometer is especially beneficial when used in premature infants, newborns, and children because there is no risk of injury to the patient or nurse. However, it is inaccurate with head covering or hair on the forehead and is affected by skin moisture such as diaphoresis or sweating. It provides very rapid measurement and reflects rapid changes in core temperature, not radiant temperature
The shivering mechanism of heat production is rarely functioning in the newborn. Nonshivering _____________ is accomplished primarily by metabolism of brown fat, which is unique to the newborn, and by increased metabolic activity in the brain, heart, and liver.
ANS: thermogenesis Brown fat is located in superficial deposits in the interscapular region and axillae, as well as in deep deposits at the thoracic inlet, along the vertebral column and around the kidneys. Brown fat has a richer vascular and nerve supply than ordinary fat. Heat produced by intense lipid metabolic activity in brown fat can warm the newborn by increasing heat production by as much as 100%.
