which action should the nurse implement when taking an axillary temperature
Logo

Nursing Elites

ATI RN

ATI Nursing Care of Children

1. Which action should the nurse implement when taking an axillary temperature?

Correct answer: C

Rationale: The correct technique involves placing the thermometer tip in the center of the axilla to ensure an accurate reading, with the arm held close to the body.

2. The nurse is interviewing the father of a 10-month-old girl. The child is playing on the floor when she notices an electrical outlet and reaches up to touch it. Her father says no firmly and moves her away from the outlet. The nurse should use this opportunity to teach the father what?

Correct answer: B

Rationale: At 10 months, children are beginning to understand simple commands like "no." It is important for parents to reinforce this understanding consistently to help the child learn about boundaries and safety.

3. A 12-month-old infant has been diagnosed with failure to thrive (FTT). Which assessment findings does the nurse expect to be documented with this infant?

Correct answer: D

Rationale: These behaviors are consistent with FTT and indicate social withdrawal, which is often observed in infants who are not thriving. A wide-eyed gaze and avoidance of eye contact can also indicate developmental delays or emotional disturbances.

4. A child with acute glomerulonephritis is in the playroom and experiences blurred vision and a headache. What action should the nurse take?

Correct answer: B

Rationale: Blurred vision and headache in a child with acute glomerulonephritis may indicate severe hypertension, which requires immediate assessment and intervention. Blood pressure should be checked, and the healthcare provider notified.

5. The clinic nurse is reviewing the immunization guidelines for hepatitis B. Which are true of the guidelines for this vaccine?

Correct answer: B

Rationale: Hepatitis B vaccination should start at birth, and any child or adolescent not vaccinated should complete the series. Adolescents should receive three doses if they were not previously vaccinated.

Similar Questions

The parent asks when the soft area in the infant's head will go away. What is the best response by the nurse?
During an otoscopic examination on an infant, in which direction is the pinna pulled?
During which phase of the nursing process does the nurse use essential information about the child’s physical, social, and emotional health to decide which interventions to use?
Which vaccine is contraindicated in a child with a history of severe egg allergy?
Ongoing fluid losses can overwhelm the child’s ability to compensate, resulting in shock. What early clinical sign precedes shock?

Access More Features

ATI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

ATI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

Other Courses