A nurse is planning to obtain a rectal temperature from a toddler. Which of the following actions should the nurse take?
Insert the tip of the thermometer 5 cm (2 in) into the rectum.
Place the child in prone position.
Stabilize the thermometer at the distal end.
Direct the tip of the thermometer toward the spine during insertion.
The Correct Answer is C
A. Insert the tip of the thermometer 5 cm (2 in) into the rectum. The correct insertion depth is 2.5 cm (1 inch) for toddlers to avoid rectal injury.
B. Place the child in prone position. The child should be placed in the side-lying or supine position with legs flexed.
C. Stabilize the thermometer at the distal end. Stabilizing the thermometer ensures it remains in position during the procedure, minimizing risk of injury.
D. Direct the tip of the thermometer toward the spine during insertion. The thermometer should be directed toward the umbilicus to follow the natural rectal curve.
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Related Questions
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}
Explanation
1. Failure to thrive: The infant has poor weight gain despite being hungry after vomiting. Projectile vomiting, as described, often leads to insufficient caloric intake, putting the infant at risk for failure to thrive.
2. Dehydration: Repeated vomiting results in fluid loss, putting the infant at high risk of dehydration, which is common in conditions like pyloric stenosis, suspected here due to the symptoms and palpable abdominal mass.
3. Intussusception typically presents with intermittent, severe abdominal pain, "currant jelly" stools, and sometimes a sausage-shaped mass, which are not noted in this scenario.
4. Meckel diverticulum can cause painless rectal bleeding or obstruction symptoms but is not associated with projectile vomiting or a palpable mass.
5. Hirschsprung disease presents with failure to pass meconium, abdominal distension, and chronic constipation rather than the projectile vomiting seen here.
Correct Answer is B
Explanation
A. "Administer the medication on an empty stomach." Phenytoin can be taken with or without food. Administering with food can reduce stomach upset.
B. "Encourage the child to brush their teeth after each meal." Phenytoin increases the risk of gingival hyperplasia, so regular brushing helps maintain oral hygiene and prevents complications.
C. "Crush the child's medication to mix with applesauce." Extended-release capsules should not be crushed as this alters their intended release mechanism.
D. "Observe the child for diarrhea." Diarrhea is not a common side effect of phenytoin. Monitoring should focus on side effects like gingival overgrowth, nystagmus, or skin rashes.
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