A nurse is obtaining the temperature of a newborn.
Which of the following sites should the nurse use?
Rectal.
Axillary.
Tympanic.
Oral.
The Correct Answer is B
The correct answer is choice B: Axillary.
Choice B rationale: The axillary site, or under the arm, is the preferred site for obtaining the temperature of a newborn. This method is safe and generally well-tolerated by infants. It carries a lower risk of injury or discomfort compared to other methods.
Choice A rationale: Rectal temperature measurement can be accurate but is more invasive and may cause discomfort or injury to the newborn. It is generally not the preferred method for routine temperature checks in newborns.
Choice C rationale: Tympanic temperature measurement, which uses the ear canal, may not be accurate for newborns due to their small ear canal size and the presence of vernix caseosa or amniotic fluid.
Choice D rationale: Oral temperature measurement is not suitable for newborns as they cannot hold the thermometer in their mouth safely or reliably. This method is more appropriate for older children and adults.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Recent myocardial infarction is not a contraindication for warfarin administration. Warfarin is often prescribed for patients with a history of myocardial infarction to prevent clot formation and reduce the risk of stroke.
Choice B rationale:
Recent eye surgery is a contraindication for the administration of warfarin. Warfarin can increase the risk of bleeding, which is particularly concerning after eye surgery due to the delicate nature of ocular tissues. Using anticoagulants in this scenario can lead to severe complications, including vision loss.
Choice C rationale:
Thrombophlebitis, inflammation of a vein with clot formation, is not a contraindication for warfarin administration. In fact, anticoagulants like warfarin are commonly prescribed to prevent the extension of clots and reduce the risk of complications associated with thrombophlebitis.
Choice D rationale:
Breast cancer is not a direct contraindication for warfarin administration. However, the decision to use anticoagulants in patients with a history of breast cancer should be made carefully, considering individual factors such as the stage of cancer, ongoing treatment, and overall risk of thromboembolic events.
Correct Answer is D
Explanation
A.Taping the tube to the child's cheek is not a recommended practice. It can cause skin irritation, discomfort, or even accidental removal of the tube. Proper securing of the tube to the abdomen using appropriate devices is the preferred method to prevent dislodgement.
B.Applying lubricant to the site is not necessary or recommended. The gastrostomy tube should be kept clean and dry. If any secretions or debris are present, they should be gently cleaned with mild soap and water, followed by thorough rinsing and drying.
C.Some gastrostomy tubes require an extension set for feeding, especially low-profile devices (e.g., button-type gastrostomy tubes). This extension makes it easier to administer feeds or medications and can be removed afterward. However, this is not typically part of routine site care.
D.Securing the tubing to the child's abdomen helps prevent accidental dislodgement or pulling of the gastrostomy tube. This can be done using appropriate securing devices, such as adhesive dressings or commercially available tube holders, as recommended by the healthcare provider.
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