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: Infants under 3 years old are typically unable to hold an oral thermometer safely under the tongue, making this method inappropriate and potentially unsafe. B. Pull the pinna of the infant's ear forward before inserting the probe: For infants under 1 year old, the pinna should be pulled down and back to properly align the ear canal for an accurate tympanic temperature reading. Pulling it forward could result in inaccurate measurements. C. Place the tip of the thermometer under the center of the infant's axilla: Axillary temperature measurement is safe and recommended for infants. The thermometer should be placed in the center of the armpit with the arm held snugly against the body to ensure an accurate reading. D. Insert the probe 3.8 cm (1.5 in) into the infant's rectum: Rectal thermometer insertion in infants should only be about 2.5 cm (1 inch) to avoid rectal perforation. Inserting 3.8 cm is too deep and unsafe for an infant.