The nurse's initial action when caring for an infant with a slightly decreased temperature is to:
a. Notify the physician immediately.
b. Place a cap on the infant's head and have the mother perform kangaroo care.
c. Tell the mother that the infant must be kept in the nursery and observed for the next 4 hours.
d. Change the formula because this is a sign of formula intolerance.
ANS: B
Keeping the head well covered with a cap will prevent further heat loss from the head, and hav-ing the mother place the infant skin to skin should increase the infant's temperature. Nursing ac-tions are needed first to correct the problem. If the problem persists after interventions, notifica-tion may then be necessary. A slightly decreased temperature can be treated in the mother's room. This would be an excellent time for parent teaching on prevention of cold stress. Mild temperature instability is an expected deviation from normal during the first days as the infant adapts to external life.
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