The nurse is caring for a 2-hour-old infant at risk for cold stress. Which of the following assessment findings would support an early finding of cold stress?
The nurse is caring for a 2-hour-old infant at risk for cold stress. Which of the following assessment findings would support an early finding of cold stress?
A. shivering
[49%]
B. hyperglycemia
[7%]
C. tachycardia
[32%]
D. bradypnea
[12%]
Statistics
Subject/Lesson
Subject
Maternal & Newborn Health
Lesson
Newborn
Client Need
Test Plan
Reduction of Risk Potential
Related Topic
Potential for Alterations in Body Systems
Item Type
Item Type
Knowledge/Comprehension
Explanation
Choice C is correct. When an infant's temperature decreases, their heart rate increases because of peripheral vasoconstriction. The vasoconstriction increases the infant's heart rate because of the increased afterload. Tachycardia, tachypnea, and cyanosis to the extremities are signs of cold stress.
Choice A is incorrect. Infants do not shiver until approximately six months. This infant is 2 hours old, and shivering is highly unlikely.
Choice B is incorrect. When an infant experiences cold stress, it causes the infant to increase their metabolic rate. The increase in metabolic rate may drive down blood glucose. Thus, it would be prudent to assess the newborn for hypoglycemia if they develop cold stress.
Choice D is incorrect. A newborn with cold stress would develop tachypnea. This is an early manifestation that would be caused by the increased demand for oxygen driving up the respiratory rate. Bradypnea would be a late sign of cold stress.
Related Videos
2 Key Topics
Infant Education & Immunizations
14.7 Infant Growth and Development
Additional Info
✓ Cold stress would deplete glucose stores because of the sympathetic response. Thus, hyperglycemia would not occur.
✓ Manifestations of hypoglycemia include poor muscle tone and a weak, jittery cry.
✓ Metabolic acidosis would develop due to cold stress because the lack of glucose would cause fat to be the fuel source, causing metabolic acidosis.
✓ Axillary temperature is the method to obtain a newborn's temperature, and the average temperature at birth is 36.5° to 37.5°C (97.7° to 99.5°F).
