Question

As a result of large body surface in relation to weight, the preterm infant is at high risk for heat loss and cold stress. By understanding the four mechanisms of heat transfer (convection, conduction, radiation, and evaporation), the nurse can create an environment for the infant that prevents temperature instability. While evaluating the plan that has been implemented, the nurse knows that the infant is experiencing cold stress when he or she exhibits:

a. Decreased respiratory rate.
b. Bradycardia followed by an increased heart rate.
c. Mottled skin with acrocyanosis.
d. Increased physical activity.

Answer 1

The correct answer is option C. The nurse knows that a preterm infant is experiencing cold stress when he or she exhibits mottled skin with acrocyanosis, which indicates poor circulation and constriction of peripheral blood vessels in an attempt to conserve heat.

Step-by-step explanation:

The question relates to how nurses can detect cold stress in preterm infants by understanding the signs that indicate the infant is losing heat through the four mechanisms of heat transfer: conduction, convection, radiation, and evaporation.

In preterm infants, these signs of cold stress can include a range of physiological responses due to their larger body surface area in relation to their weight, which leads to rapid heat loss.

The correct answer for the given options is that the nurse knows the infant is experiencing cold stress when he or she exhibits: c. Mottled skin with acrocyanosis.

This is because mottled skin and acrocyanosis (bluish discoloration of the extremities) are signs of poor circulation, which commonly occur during cold stress when peripheral blood vessels constrict to preserve core body temperature.

While decreased respiratory rate may signal other health issues and increased physical activity can be an attempt to generate heat, they are not specific indicators of cold stress with the level of reliability of mottled skin with acrocyanosis.

Bradycardia followed by an increased heart rate may be symptomatic of other severe conditions that warrant urgent investigation rather than typical cold stress response.