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