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

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

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

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

Insert the probe 3.8 cm (15 in into the infant's rectum

Answer and Explanation

The Correct Answer is A

A. Place the tip of the thermometer under the center of the infant's axilla: This is the correct method for taking an axillary temperature in infants, which is the recommended route due to safety and ease. The tip should be placed snugly in the center of the axilla and the infant's arm should be held firmly against their body to ensure accuracy.
B. Pull the pinna of the infant's ear forward before inserting the probe: This technique is used for otoscopic or tympanic temperature readings in children under 3, but tympanic readings are not preferred in young infants due to the small size and curvature of their ear canals, which can lead to inaccuracy.
C. Insert the oral thermometer in front of the infant's tongue: Oral temperature measurement is inappropriate for infants. They may not be able to keep the thermometer properly positioned, which increases the risk of inaccurate readings or injury.
D. Insert the probe 3.8 cm (1.5 in) into the infant's rectum: Rectal temperature measurement is not routinely recommended unless specifically indicated, and the probe should only be inserted about 1.3 cm (0.5 in) for infants to avoid rectal perforation. The option listed suggests unsafe depth.

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Correct Answer is B

Explanation

A. Place a small, folded blanket behind the baby's neck to provide support while in the car seat. Adding extra padding behind the infant’s neck is not recommended, as it can alter the positioning and compromise the safety design of the car seat. Only manufacturer-approved inserts should be used.
B. Anchor the car seat in a rear-facing position in the back seat of the vehicle. Infants under the age of 2 should always be placed in a rear-facing car seat in the back seat. This position offers the best protection for the infant’s head, neck, and spine in the event of a crash.
C. Ensure the water heater temperature is set to no more than 54° C (129.2° F). This temperature is too high and increases the risk of scalding. The recommended maximum temperature for a household water heater is 49° C (120° F) to ensure infant safety.
D. Cover the baby with a cotton blanket when they are asleep. Using loose bedding, including blankets, increases the risk of sudden infant death syndrome (SIDS). Instead, the infant should sleep in a wearable blanket or sleep sack on a firm mattress without soft items.

A. Explain long term consequences of the procedure to the child. B. Remove the dressings while explaining the procedure to the child. C. Keep equipment out of the child's sight. D. Allow the child to help remove the dressings.

Correct Answer is D

Explanation

A. Explain long term consequences of the procedure to the child. This level of detail is not developmentally appropriate for a school-age child. It may increase anxiety without helping the child understand or cope with the immediate situation.
B. Remove the dressings while explaining the procedure to the child. While it is important to explain procedures, it should be done before starting to allow time for questions and emotional preparation. Explaining during may cause confusion or distraction.
C. Keep equipment out of the child's sight. Hiding equipment can actually increase fear and mistrust. School-age children benefit from open, age-appropriate communication and preparation about what to expect.
D. Allow the child to help remove the dressings. This is the most appropriate action. Allowing the child to participate in their care provides a sense of control, reduces anxiety, and helps build trust. It also aligns with the developmental need of school-age children to take on increasing responsibility and be involved in decision-making.

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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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