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.

Answer and Explanation

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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Correct Answer is ["B","C","D","E"]

Explanation

A. Bruises easily. Easy bruising is more commonly associated with hematologic conditions, not brain tumors.
B. Clumsiness. Clumsiness or difficulty with coordination may indicate motor function impairment caused by a brain tumor.
C. Irritability. Irritability can result from increased intracranial pressure (ICP) or other neurological changes due to a brain tumor.
D. Persistent headaches. Persistent headaches, especially those worse in the morning, are a common sign of increased ICP from a brain tumor.
E. Vomiting. Vomiting, particularly without nausea, can occur due to increased ICP.

A. Bounding peripheral pulses B. Cyanotic spells C. Stridor D. Anemia E. heart murmur

Correct Answer is ["B","E"]

Explanation

A. "Bounding peripheral pulses." Bounding pulses are not characteristic of Tetralogy of Fallot. Instead, pulses may be normal or diminished, depending on the severity of the defect.
B. "Cyanotic spells." Tetralogy of Fallot causes decreased oxygenation, leading to periodic cyanotic episodes, particularly during crying or feeding ("tet spells").
C. "Stridor." Stridor is associated with upper airway obstructions, not cardiac defects like Tetralogy of Fallot.
D. "Anemia." Anemia is not a primary finding in Tetralogy of Fallot. Polycythemia (increased red blood cells) is more common due to chronic hypoxia.
E. "Heart murmur." A systolic murmur is common due to the pulmonary stenosis and ventricular septal defect associated with Tetralogy of Fallot.

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A nurse is planning to obtain a rectal temperature from a toddler. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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