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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Tell the nurses that the assignments will be more equitable in the future. While this acknowledges their concern, it does not involve the nurses in the resolution process or address the root of the conflict through direct communication.
B. Ask each nurse to take turns making the assignments. This may temporarily reduce tension but avoids addressing the underlying issues of perceived favoritism and does not encourage collaboration or accountability.
C. Encourage collaboration between the two nurses when making the assignments. This approach promotes open communication, mutual understanding, and shared decision-making, which are key elements of collaborative conflict resolution. It allows both nurses to express their perspectives and work toward a fair and balanced outcome.
D. Arrange for the nurses to have as few shifts together as possible. This strategy avoids the conflict rather than resolving it, which may only delay or worsen interpersonal issues over time. It also limits opportunities for growth and team building.
Correct Answer is D
Explanation
A. "Why are you eating seaweed soup?" This response is judgmental and dismissive of the client’s cultural practices. It can make the client feel misunderstood or disrespected.
B. "The hospital food is more nutritious for you." This statement is inaccurate and culturally insensitive, assuming that hospital food is superior without recognizing the nutritional and emotional value of traditional foods.
C. "Does the doctor know that you are eating that?" This implies unnecessary medical concern and may make the client feel like her personal choices require approval, which can be disempowering and disrespectful.
D. "Of course, I will heat that up for you." This response is supportive and culturally competent, respecting the client's traditions and preferences while promoting comfort and emotional well-being during the postpartum period.
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