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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Bleeding gums: Mild bleeding gums can occur during pregnancy due to increased vascularity and hormonal changes. While uncomfortable, this finding is generally not urgent and can be managed with routine oral care.
B. Fundal height of 26 cm: A fundal height slightly above the gestational age (24 weeks vs. 26 cm) may be within normal variation, especially if the client has a larger fetus or multiple gestations. It should be monitored but is not immediately concerning.
C. Periorbital edema: Swelling around the eyes can be an early sign of preeclampsia, a potentially serious pregnancy complication. This finding should be reported promptly to the provider for further assessment and management.
D. White vaginal discharge: Mild, white, and non-odorous discharge (leukorrhea) is common during pregnancy due to hormonal changes. It is typically considered normal unless accompanied by odor, itching, or irritation.
Correct Answer is A
Explanation
Rationale:
A. Maintain the irrigation solution rate: Pink-tinged urine is expected in the early hours after a TURP due to residual bleeding from the surgical site. The nurse should continue the current irrigation rate to prevent clot formation and maintain catheter patency.
B. Warm the irrigation solution: Warming the solution is not required for bladder irrigation and does not address the normal postoperative finding of pink-tinged urine. It also does not play a role in preventing clot formation.
C. Perform the Credé's maneuver: This technique, involving manual bladder compression, is not appropriate for a client with a continuous bladder irrigation and indwelling catheter in place. It could cause injury or disrupt the surgical site.
D. Replace the indwelling urinary catheter: There is no indication of catheter blockage or malfunction in this scenario. Replacing the catheter unnecessarily increases infection risk and could damage the urethra or surgical area.
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