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 ["B","D","E"]
Explanation
A. Refute the client's delusions using logic: Confronting or trying to correct delusions can increase agitation and confusion in clients with dementia. This approach is not therapeutic and should be avoided.
B. Give the client one simple direction at a time: Providing clear, single-step instructions reduces confusion and helps the client successfully complete tasks, supporting independence and minimizing frustration.
C. Allow the client to choose among a variety of activities each day: Offering too many choices can overwhelm a client with dementia, leading to anxiety and agitation. It is more effective to offer a simple choice between two options or to provide a structured routine to reduce decision fatigue.
D. Establish eye contact when communicating with the client: Eye contact enhances attention, conveys respect, and improves comprehension during interactions, which is particularly important for clients with cognitive impairment.
E. Reinforce orientation to time, place, and person: Gentle reminders and reorientation cues help maintain cognitive function, reduce anxiety, and support the client’s awareness of their environment.
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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