A nurse is preparing to measure the temperature of an infant. Which of the following actions should the nurse take?

Pull the pinna of the infant's ear forward before inserting the probe.

Insert the probe 3.8 cm (1.5 in) into the infant's rectum.

Place the tip of the thermometer under the center of the infant's axilla.

Insert the oral thermometer in front of the infant's tongue.

Answer and Explanation

The Correct Answer is C

Rationale:

A. Pull the pinna of the infant's ear forward before inserting the probe: For infants, the pinna should be pulled down and back, not forward, to align the ear canal properly for accurate tympanic temperature measurement.

B. Insert the probe 3.8 cm (1.5 in) into the infant's rectum: Rectal insertion for infants should be limited to 2.5 cm (1 in) or less to avoid rectal perforation and injury. Inserting 3.8 cm is unsafe.

C. Place the tip of the thermometer under the center of the infant's axilla: Axillary temperature measurement is safe and commonly used in infants. Placing the tip in the center of the axilla and holding the arm snugly ensures accurate contact and reading.

D. Insert the oral thermometer in front of the infant's tongue: Infants cannot reliably hold a thermometer under their tongue, making oral measurement inaccurate and unsafe due to risk of swallowing or injury.

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Correct Answer is ["A","C","E"]

Explanation

A. Activity level: Restlessness, pacing, and inability to remain seated are early neurological manifestations of water intoxication, stemming from cerebral edema related to hyponatremia. These signs often precede more severe symptoms like seizures.

B. White blood cell count: A count of 9,100/mm³ is within normal limits and does not indicate water intoxication. This value is unrelated to the dilutional effects of excessive fluid intake.

C. Sodium level: A sodium of 130 mEq/L indicates hyponatremia, which is a hallmark laboratory finding in water intoxication due to dilutional effects from excess fluid intake. Low sodium can cause neurological changes and altered mental status.

D. Potassium level: A potassium of 3.6 mEq/L is within the normal range and does not support a diagnosis of water intoxication. Potassium is less affected by acute overhydration compared to sodium.

E. Hallucinations: Responding to unseen stimuli can occur when hyponatremia causes cerebral swelling, disrupting normal brain function. In clients with psychotic disorders, excess water intake can exacerbate hallucinations or make them more pronounced.

A. Clostridium difficile B. Herpes simplex virus C. Chlamydia trachomatis D. Human papilloma virus

Correct Answer is C

Explanation

A. Clostridium difficile: C. difficile infections are typically managed within healthcare facilities and are not considered reportable to local health departments under standard public health reporting requirements.

B. Herpes simplex virus: HSV infections are common and usually not reportable to public health authorities, except in cases of neonatal herpes or unusual outbreaks, as routine cases are managed clinically.

C. Chlamydia trachomatis: Chlamydia is a sexually transmitted infection that is nationally notifiable. Reporting to the local health department is required to track incidence, prevent spread, and facilitate partner notification and treatment.

D. Human papilloma virus: HPV infections are widespread and typically not reportable because most cases are asymptomatic or self-limiting. Reporting is not required for routine surveillance or treatment purposes.

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A nurse is preparing to measure the temperature of an infant. Which of the following actions should the nurse take?

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