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

A.

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

B.

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

C.

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

D.

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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Related Questions

Correct Answer is C

Explanation

A. Schedule the client for an aPTT test. An aPTT (activated partial thromboplastin time) test is used to monitor heparin therapy and is not relevant following an amniocentesis unless the client has a known bleeding disorder, which is not indicated here.
B. Collect a blood sample from the client for a direct Coombs test. The direct Coombs test is typically performed on newborns, not the mother, to detect antibodies attached to red blood cells. It is not a routine part of post-amniocentesis care.
C. Monitor the client for uterine contractions. After an amniocentesis, it is essential to monitor for signs of preterm labor, including uterine contractions. The procedure can irritate the uterus and potentially trigger contractions, especially at 34 weeks gestation.
D. Administer Rho(D) Immune globulin if the client is Rh positive. Rho(D) Immune globulin is given to Rh-negative clients after procedures like amniocentesis to prevent isoimmunization. It is not indicated for Rh-positive individuals.

Correct Answer is A

Explanation

A. "Purchase a gift to give to your son from your baby." This is an effective strategy to help a young child feel included and valued, easing the transition and reducing potential jealousy. It fosters a positive emotional connection between the older sibling and the newborn.
B. "Make sure you are holding your baby when your son comes to visit you in the hospital." This may unintentionally make the child feel replaced or left out. It’s better for the parent to be free to hug and reassure the older child during the initial visit.
C. "Use medical terminology when teaching your son about your new baby." Medical terms may confuse or overwhelm a 4-year-old. Simple, age-appropriate language is more effective in helping the child understand the upcoming changes.
D. "Surprise your son with a new bedroom after you bring the baby home." Sudden changes can be disorienting or upsetting for young children. Involving them in the transition process before the baby arrives helps foster a sense of control and comfort.

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