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. 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.
Correct Answer is A
Explanation
Rationale:
A. The client brushes her teeth twice daily: Brushing teeth at least twice a day is recommended to reduce plaque buildup, prevent tooth decay, and maintain oral health. This practice is consistent with standard personal hygiene guidelines.
B. The client wipes back to front when toileting: Wiping from back to front increases the risk of transferring bacteria from the anal area to the urethra, which can lead to urinary tract infections. The correct method is front to back.
C. The client washes her perineum first when bathing: The perineal area should be washed last to avoid transferring bacteria from this region to other parts of the body, especially the face. Washing it first increases the risk of cross-contamination.
D. The client takes a hot bubble bath every day: Daily hot bubble baths can dry out the skin and disrupt normal skin flora, potentially leading to irritation or infection. Mild, less frequent bathing with warm (not hot) water is healthier for skin integrity.
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