What assessment finding indicates to the nurse that goals for the diagnosis of ineffective thermoregulation related to newborn's immature temperature regulatory system have been met?
A.
Axillary temperature is 98.1 °F (36.7 °C).
B.
Fluctuations in infant's temperature cease.
C.
Baby stops shivering and falls asleep.
D.
Rectal temperature is 101.0 °F (38.3 °C).
ANS: A
The normal range for newborn temperature is 97.7 °-98.6 °F (36.5 °-37.0 °C). A stable temperature within this range demonstrates that goals for this diagnosis have been met. "Fluctuations in infant's temperature cease" is vague, and the temperature may have stabilized at a level that is too high or too low. Infants can't shiver. Axillary, not rectal, temperatures are taken; the temperature may also be assessed via continuous skin probe, or tympanic or temporal artery thermometry.
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