EAQ Thermoregulation

In which order would the nurse perform the following actions to administer eardrops to a preschooler? 1.Clean the outer ear with a washcloth. 2.Place the preschooler in a side-lying position. 3.Straighten the ear canal by pulling the auricle up and out. 4.Instill prescribed drops while holding the dropper 1 cm above ear canal. 5.Keep the child in side-lying position for 2 to 3 minutes. 6.Apply gentle massage or pressure to tragus of ear with finger.

1.Clean the outer ear with a washcloth. 2.Place the preschooler in a side-lying position. 3.Straighten the ear canal by pulling the auricle up and out. 4.Instill prescribed drops while holding the dropper 1 cm above ear canal. 5.Keep the child in side-lying position for 2 to 3 minutes. 6.Apply gentle massage or pressure to tragus of ear with finger.

The nurse is measuring the body temperature of four neonates born at term in a pediatric health setting. Which neonate has normal body temperature? 1. Neonate 1 (35.5 Celcius) 2. Neonate 2 (36 Celcius) 3. Neonate 3 (37.1 Celcius) 4. Neonate 4 (38.5 Celcius)

3. Neonate 3 (37.1 Celcius)

Which is the nurse's initial action immediately after assisting with a precipitous birth in the triage area of the emergency department? A. Warming the newborn B. Clamping the umbilical chord C. Assessing maternal bleeding D. Monitoring expulsion of the placenta

A. Warming the newborn

Which steps would the nurse take to measure the temperature of a 4-year-old child using an electronic infrared thermometer? Select all that apply. One, some, or all responses may be correct. 1. Pull the pinna up and out. 2. Pull the pinna down and back. 3. Avoid applying pressure to the ejection button. 4. Obtain the temperature from client's right ear if the nurse is right-handed. 5. Rapidly remove the probe from the ear canal.

1. Pull the pinna up and out. 3. Avoid applying pressure to the ejection button. 4. Obtain the temperature from client's right ear if the nurse is right-handed.

Which nursing action would the nurse take for an infant after reporting a fever of 103.0°F (39.4°C) to the practitioner? 1. Covering the infant with a bath blanket 2. Sponging the infant with tepid alcohol 3. Removing excess clothing from the infant 4. Reassessing the infant's temperature in several hours

3. Removing excess clothing from the infant

Which antipyretic medication may cause Reye syndrome in children? A. Aspirin B. Naproxen C. Ibuprofen D. Dantrolene

A. Aspirin

A client gives birth to a full-term male with an 8/9 Apgar score. Which would be included in the immediate nursing care of this newborn? A. Drying him off, assessing respirations, and identifying him B. Applying an antibiotic to the eyes, administering vitamin K, and bathing him C. Aspirating the oropharynx, rushing him to the nursery, and stimulating him D. Weighing him, placing him in a crib, and waiting until the mother is ready to hold him

A. Drying him off, assessing respirations, and identifying him

Which mechanism does a newborn use to maintain their body temperature? Select all that apply. One, some, or all responses may be correct. A. Flexed fetal position B. Hepatic insulin stores C. Brown fat metabolism D. Peripheral vasoconstriction E. Parasympathetic nervous system

A. Flexed fetal position C. Brown fat metabolism D. Peripheral vasoconstriction

Which component of nursing care is most important for a newborn with respiratory distress syndrome (RDS)? A. Keeping the infant in a warm environment B. Turning the infant frequently to prevent apnea C. Tapping the infant's toes to stimulate deep breathing D. Maintaining the infant's oxygen administration level at the same rate

A. Keeping the infant in a warm environment

After a newborn has skin-to-skin contact with the mother, the nurse places the newborn under a radiant warmer. Which complication is the nurse attempting to prevent? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis

A. Metabolic acidosis

The nurse is reevaluating a newborn who had an axillary temperature of 97°F (36.1°C) and was placed skin to skin with the mother. The newborn's axillary temperature is still 97°F (36.1°C) after 1 hour of skin-to-skin contact. Which intervention would the nurse implement next? A. Placing the newborn under a radiant warmer and attaching a skin probe B. Checking the newborn for a wet diaper and then continuing the skin-to-skin contact C. Leaving the newborn in skin-to-skin contact and rechecking the temperature in 1 hour D. Double-wrapping the newborn in warm blankets and returning the newborn to a crib by the mother's bedside

A. Placing the newborn under a radiant warmer and attaching a skin probe

A parent tells the nurse in the emergency department, "My 3-year-old has had a fever for several days and has been vomiting." After prescribed measures to reduce the fever have been instituted, which nursing action is most important? A. Preventing shivering B. Restricting oral fluids C. Measuring output hourly D. Taking vital signs hourly

A. Preventing shivering

Which is the nurse's initial intervention for the child who presents in the emergency department with sustained frostbite of the toes? A. Rapidly rewarming the toes by placing the feet in warm water B. Slowly rewarming the toes by wrapping the feet in a warm cloth C. Placing the feet in cool water to minimize the temperature difference D. Wrapping the feet in an ice pack until definitive medical help is available

A. Rapidly rewarming the toes by placing the feet in warm water

During the assessment of a preterm neonate the nurse determines that the infant is experiencing hypothermia. Which action would the nurse take? A. Rewarm gradually B. Notify the practitioner C. Assess for hyperglycemia D. Record skim temperature hourly

A. Rewarm gradually

Which condition would the nurse suspect is the cause of the increased temperature in a client with a temperature of 100.4°F (38°C) 12 hours after a spontaneous vaginal birth? A. Mastitis B. Dehydration C. Puerperal infection D. Urinary tract infection

B. Dehydration

The nurse is preparing to bathe a neonate born at 30 weeks' gestation. Which practices ensure the infant's safety? Select all that apply. One, some, or all responses may be correct. A. Gives the neonate a daily warm-water bath B. Immerses the neonate fully except the head in the tub C. Measures the body temperature within 2 to 4 hours before giving the bath D. Removes the vernix completely from the neonate's skin while giving the bath E. Uses cleansing agents with neutral pH and minimal dyes while giving the bath

B. Immerses the neonate fully except the head in the tub C. Measures the body temperature within 2 to 4 hours before giving the bath E. Uses cleansing agents with neutral pH and minimal dyes while giving the bath

How does a healthy full-term neonate produce body heat? A. Shivering when chilled B. Metabolism of brown fat C. Oxidization of fatty acids D. Increased muscular activity

B. Metabolism of brown fat

Which method would the nurse use to measure the temperature of a 4-year-old child with leukemia who has mucositis? Select all that apply. One, some, or all responses may be correct. A. Digital, rectal B. Electric, oral C. Infrared, tympanic D. Sensor, ear-based E. Temporal artery

C. Infrared, tympanic E. Temporal artery

Immediately after birth, a newborn is dried before being placed in skin-to-skin contact with the mother. Which type of heat loss would this intervention prevent? A. Radiation B. Convection C. Conduction D. Evaporation

D. Evaporation

A newborn is experiencing cold stress while being admitted to the nursery. Which nursing goal has the highest immediate priority? A. Minimize shivering B. Prevent hyperglycemia C. Limit oxygen consumption D. Prevent metabolism of fat stores

D. Prevent metabolism of fat stores