A nurse is preparing to measure the temperature of an infant. Which of the following actions should the nurse take?

Place the tip of the thermometer under the center of the infant's axilla

Pull the pinna of the Infant's ear forward before inserting the probe.

Insert the oral thermometer in front of the infant's tongue.

Insert the probe 3.8 cm (15 in into the infant's rectum

Answer and Explanation

The Correct Answer is A

A. Place the tip of the thermometer under the center of the infant's axilla: This is the correct method for taking an axillary temperature in infants, which is the recommended route due to safety and ease. The tip should be placed snugly in the center of the axilla and the infant's arm should be held firmly against their body to ensure accuracy.
B. Pull the pinna of the infant's ear forward before inserting the probe: This technique is used for otoscopic or tympanic temperature readings in children under 3, but tympanic readings are not preferred in young infants due to the small size and curvature of their ear canals, which can lead to inaccuracy.
C. Insert the oral thermometer in front of the infant's tongue: Oral temperature measurement is inappropriate for infants. They may not be able to keep the thermometer properly positioned, which increases the risk of inaccurate readings or injury.
D. Insert the probe 3.8 cm (1.5 in) into the infant's rectum: Rectal temperature measurement is not routinely recommended unless specifically indicated, and the probe should only be inserted about 1.3 cm (0.5 in) for infants to avoid rectal perforation. The option listed suggests unsafe depth.

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Correct Answer is C

Explanation

A. Decrease the maintenance infusion rate of IV fluid. Epidural anesthesia can cause hypotension, so IV fluids are often used to help maintain blood pressure. Reducing the fluid rate may increase the risk of hypotensive episodes.
B. Have protamine sulfate available at the bedside. Protamine sulfate is the antidote for heparin, not relevant to epidural anesthesia. It is not required in the management of epidural-related side effects.
C. Reposition the client side-to-side each hour. Frequent repositioning helps prevent pressure injuries, promotes fetal oxygenation, and encourages effective labor progression. It also aids in the distribution of the anesthetic agent.
D. Monitor the client for hypertension. Hypotension, not hypertension, is a common adverse effect of epidural anesthesia due to vasodilation and decreased peripheral resistance. Blood pressure should be monitored closely for drops.

A. Naltrexone B. Chlordiazepoxide C. Clonidine D. Bupropion

Correct Answer is D

Explanation

A. Naltrexone. This medication is used for opioid and alcohol use disorders. It helps reduce cravings and the pleasurable effects of those substances but is not indicated for smoking cessation.
B. Chlordiazepoxide. This is a benzodiazepine used to manage alcohol withdrawal symptoms, such as anxiety, tremors, and agitation. It is not appropriate for treating nicotine dependence.
C. Clonidine. Although primarily used for hypertension, clonidine has been used off-label to manage symptoms of opioid or nicotine withdrawal. However, it is not the first-line agent for smoking cessation.
D. Bupropion. This is an antidepressant also approved for smoking cessation. It helps reduce nicotine cravings and withdrawal symptoms and is often prescribed under the brand name Zyban for this purpose.

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