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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?

A.

Insert the tip of the thermometer 5 cm (2 in) into the rectum.

B.

Place the child in prone position.

C.

Stabilize the thermometer at the distal end.

D.

Direct the tip of the thermometer toward the spine during insertion.

E.

None

F.

None

Answer and Explanation

The Correct Answer is B


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Related Questions

Correct Answer is B

Explanation

A. Urine output of 50 mL in 2 hr: This is within normal limits for a child and does not indicate an immediate concern.
B. Lethargy: Lethargy is a potential sign of increased intracranial pressure (ICP), which is a critical complication of VP shunt placement and requires immediate intervention.
C. Respiratory rate 24/min: This is within the normal range for a 4-year-old child.
D. Absent Babinski reflex: This is a normal finding in children over 2 years old, as the reflex typically disappears by that age.

Correct Answer is D

Explanation

A. "I will set the temperature of the hot water heater to 140 degrees." The hot water heater should be set to 120°F (49°C) or lower to prevent scald injuries. A setting of 140°F significantly increases the risk of burns.
B. "I will turn pot handles towards the front of the stove when cooking." Pot handles should be turned toward the back of the stove to prevent a child from grabbing or knocking them over.
C. "I don't need to apply sunscreen to my child if he is outside after 3 p.m." Sunscreen is essential any time a child is outdoors during daylight, regardless of the time, to protect against harmful UV rays.
D. "I will plug protective guards into my electrical outlets." Installing protective guards helps prevent electrical burns by stopping toddlers from inserting objects into outlets.

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