The young mother of an 8-month-old patient brought her daughter to the clinic after taking the little girl's temperature rectally and obtaining a reading of 100.4 F. The mother was concerned that her daughter might be ill. Which of the following is the best response?
"When taking multiple temperature, the sites should be rotated."
"Because of her age, it is probably a bacterial infection."
"Children usually run lower rather than higher temperatures when ill."
"Rectal temperature readings are higher than temperature obtained orally."
The Correct Answer is D
A. "When taking multiple temperatures, the sites should be rotated.":
This does not address the mother’s concern about the specific temperature reading and its significance.
B. "Because of her age, it is probably a bacterial infection.":
A temp of 100.4°F is low-grade and not diagnostic of bacterial infection, especially in an infant without other symptoms.
C. "Children usually run lower rather than higher temperatures when ill.":
Children often run higher fevers when ill, not lower.
D. "Rectal temperature readings are higher than temperature obtained orally.":
Rectal temperatures are typically 0.5°F to 1°F higher than oral readings. A rectal temp of 100.4°F is considered the threshold for fever in infants but may still be within normal for a well-appearing child.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Massage reddened areas during dressing changes:
Massaging reddened or compromised skin can worsen tissue damage and increase the risk of further injury.
B. Apply a heat lamp twice a day:
Heat lamps are not recommended and may dry out the wound bed or burn healing tissue.
C. Cleanse with 0.9% sodium chloride irrigation:
Normal saline is gentle and effective for cleaning granulating tissue without causing damage or cytotoxic effects.
D. Cleanse with povidone-iodine solution:
Povidone-iodine is cytotoxic and can impair wound healing, especially to new granulating tissue.
Correct Answer is ["A","B","C","D","E"]
Explanation
T 38°C (100.4°F), oral
The temperature has decreased from 38.9°C to 38.0°C, showing improvement in fever, likely due to rehydration and reduced systemic inflammation.
BP 106/60 mm Hg, supine
Blood pressure has improved from a hypotensive state (88/56) to a more stable reading, indicating effective fluid resuscitation.
HR 99/min
Heart rate decreased from 112/min to 99/min, indicating reduced compensatory tachycardia, likely due to improved fluid volume status.
R 20/min
Respiratory rate is within normal limits and stable; no signs of respiratory compromise.
Pulse oximetry 95% on room air
Oxygen saturation is maintained within normal range without supplemental oxygen, indicating adequate perfusion and oxygenation.
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