The nurse caring for small-for-gestational-age (SGA) infants assesses them for attainment of outcomes related to nursing diagnoses. Which assessment finding best demonstrates attainment of priority outcomes?
A.
Body temperature of 97.5 °F (36.4 ° C)
B.
Gains weight regularly
C.
Parents visit daily
D.
Skin remains intact
ANS: B
The SGA infant has several important nursing diagnoses, including risk for activity intolerance related to increased metabolic needs, risk for ineffective feeding pattern related to increased metabolic need, and nutritional imbalance related to hypoglycemia. The fact that this infant is gaining weight demonstrates that he or she is meeting outcomes related to all three diagnoses. A body temperature of 97.5 °F is too cool for removal of the baby from the incubator. Parental involvement may indicate no unmet psychosocial needs on their part, but physical diagnoses take precedence over psychosocial ones. Intact skin is a good finding, but risk for impaired skin integrity would not be a higher priority than the other three.
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