Newborn Nursing Care Q 25
A neonate is admitted to a hospital’s central nursery. The neonate’s vital signs are: temperature = 96.5 degrees F., heart rate = 120 bpm, and respirations = 40/minute. The infant is pink with slight acrocyanosis. The priority nursing diagnosis for the neonate is:
A. Ineffective thermoregulation related to fluctuating environmental temperatures.
B. Potential for infection related to lack of immunity.
C. Altered nutrition, less than body requirements related to diminished sucking reflex.
D. Altered elimination pattern related to lack of nourishment.
Correct Answer: A. Ineffective thermoregulation related to fluctuating environmental temperatures.
Option A: Normal newborn temperature is around 97.8 to 98.8 F (axillary). Newborns have very small bodies and don’t produce much heat themselves, but they readily absorb heat when they are held. Most cooling of the newborn occurs immediately after birth. During the first 10 to 20 minutes, the newborn may lose enough heat for the body temperature to fall by 2-4°C if appropriate measures are not taken. Continued heat loss will occur in the following hours if proper care is not provided. The temperature of the environment during delivery and the postnatal period has a significant effect on the risk to the newborn of developing hypothermia.