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    RN Comprehensive Predictor 2023 Proctored Exam

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

    Explanation & Rationale

    A. Insert the oral thermometer in front of the infant's tongue: Oral temperature is not recommended for infants due to the risk of injury and difficulty keeping the thermometer in place. B. Place the tip of the thermometer under the center of the infant's axilla: The axillary route is safe and appropriate for infants. Ensuring the tip is in full contact with the skin in the center of the axilla ensures a more accurate reading. C. Pull the pinna of the infant's ear forward before inserting the probe: For infants under 3 years, the pinna should be pulled down and back to straighten the ear canal, not forward. D. Insert the probe 3.8 cm (1.5 in) into the infant's rectum: This depth is excessive for an infant; rectal insertion should be only about 1.3 to 2.5 cm (0.5 to 1 in) to avoid rectal trauma.

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