The patient is a 1-year-old male infant who is admitted with possible sepsis.The patient is irritable and agitates easily.What should the nurse do to assess the patient's temperature?
A)Take an oral temperature before doing anything else.
B)Take an axillary temperature using the upper axilla.
C)Place the child in Sims' position for a rectal temperature.
D)Take a rectal temperature as the last vital sign.

Question

Quizplus · Accepted Answer

Critically ill children sometimes have cool skin but a high core temperature because of poor perfusion to the skin.Children may assume the prone position for rectal temperature measurement.With children who cry or are restless,it is best to take temperature as the last vital sign.Use axillary temperatures for screening purposes only,not to detect fevers in infants and young children.Use the lower axilla to record temperature in side-lying infants.

The Patient Is a 1-Year-Old Male Infant Who Is Admitted