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. Personalize the conflict: Making a conflict personal can increase tension and defensiveness among staff. Effective negotiation requires addressing issues objectively rather than targeting individuals.
B. Identify solutions prior to negotiation: Preselecting solutions may limit collaborative problem-solving. Effective negotiation involves exploring options with all parties to reach mutually acceptable outcomes.
C. Attempt to understand both sides of the issue: Understanding each party’s perspective promotes open communication, trust, and collaboration. This approach helps identify common ground and develop solutions that are acceptable to all involved.
D. Focus on how the conflict occurred: Concentrating on past events can create blame and hinder forward-focused problem-solving. Effective negotiation emphasizes current needs and potential solutions rather than dwelling on the cause.
Correct Answer is C
Explanation
A. Explaining the steps for a 24-hr urine collection: Teaching and explaining procedures require nursing knowledge and judgment, which are outside the scope of practice for assistive personnel.
B. Interpreting blood glucose values: Interpretation of lab results requires clinical judgment and assessment skills, which must be performed by a licensed nurse.
C. Performing postmortem care: Postmortem care is a noninvasive task that focuses on preparing the body, maintaining dignity, and basic hygiene. This task is within the scope of practice for assistive personnel.
D. Assisting with low-carbohydrate diet selections: Assisting with dietary teaching or making food choices involves clinical guidance and education, which must be performed by a licensed nurse or dietitian rather than an assistive personnel.
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