PEDS--Rectal Temp study guide with complete solutions

Notes Inaccurate temperature measurement can result in serious errors in diagnosis and treatment. Do not use rectal temperature measurement in children who are immunocompromised or thrombocytopenic, have undergone recent anorectal surgery, or are on anticoagulant therapy. Do not use an electronic thermometer intended for multiple children for a child who needs protective isolation; use a single-use digital thermometer instead. 1. The nurse is preparing to take a child's rectal temperature. What would be the first step? C. Review laboratory test results. Rationale: The first step is to determine the risks of injury or infection. Reviewing laboratory test results helps identify conditions such as thrombocytopenia or neutropenia that can result in injury or infection if the rectal route is used. The nurse should always ensure adequate privacy, answer questions, assess the child's ability to cooperate, and explain the procedure to the child and family; however, the laboratory results are reviewed first to determine the best method of temperature assessment for the child. 00:03 01:14 2. The nurse preceptor is educating the graduate nurse about contraindications to rectal temperature measurement in children. What response from the graduate nurse indicates the teaching was effective? B. "A child with fever and neutropenia should not have rectal temperatures taken." Rationale: A child with fever and neutropenia is at high risk for infection and should not have rectal temperatures taken; any injury to the rectal mucosa and resulting contamination can lead to infection and sepsis. A child with a coagulation disorder (e.g., thrombocytopenia) is at risk for bleeding and should not have rectal temperatures taken. Taking a rectal temperature on a child who has had recent rectal surgery will cause pain and may disrupt a healing incision. Hypothermia is not a contraindication for taking a rectal temperature. 3. The nurse is preparing to assess a rectal temperature on a child. What would be important for the nurse to consider? A. The side-lying position with hips flexed facilitates insertion. Rationale: When obtaining a rectal temperature measurement, the nurse can place the child in the prone or supine position if preferred, but the optimal position is the side-lying position with the hips flexed to facilitate insertion of the thermometer. A well-lubricated probe should be inserted through the anal sphincter into the rectum no more than 2.5 cm (1 in) for children and 1.5 cm (approximately ½ in) for infants to avoid rectal injury. The lubricant should be water-soluble. Electronic thermometer devices are effective in measuring a child's temperature. 4. When preparing to assess a rectal temperature measurement on a school-age child, what would be an appropriate first step by the nurse? B. Provide privacy. Rationale: Providing privacy helps maintain modesty. The probe needs to be lubricated after privacy is assured. Repositioning the child is necessary after providing privacy. Removing the child's clothing is unnecessary; the nurse should expose just the necessary area. Proper positioning is important for rectal temperature measurements, but privacy should be provided first. 5. The nurse preceptor is educating the graduate nurse on thermoregulation in infants and children. What response by the graduate nurse indicates good understanding? A. "The larger body surface area of infants puts them at risk for heat loss." Rationale: The larger body surface area of infants allows for increased heat loss. Environmental changes do influence body temperature. Infants maintain body temperature through a chemical nonshivering thermogenesis. Heat can be lost through environmental factors such as evaporation, conduction, and convection; whereas metabolism is heat production. 6. What site is considered the gold standard for pediatric temperature measurement in the critically ill or unstable child? C. Rectal Rationale: Rectal measurement is considered the gold standard for pediatric temperature measurement in critically ill or unstable children because it is least influenced by the environment. Temporal and axillary measurements are often preferred in stable children as they are quick and less invasive though influenced by ambient temperature. Oral measurement is often used but is easily influenced by the intake of hot or cold liquids or foods. 7. Through which mechanism do infants maintain body temperature? D. Brown fat breakdown Rationale: Because of their inability to shiver, infants maintain body temperature through a chemical nonshivering thermogenesis that begins with the secretion of norepinephrine and results in the breakdown of brown fat to create heat. Conduction and convection are all environmental factors through which infants lose heat. 8. Which environmental factor would the nurse recognize as contributing to ineffective thermoregulation in infants and children? A. Excessive clothing Rationale: Environmental factors affecting thermoregulation in infants and children include skin moisture, excessive or insufficient clothing, and inadequate heat or humidity. Reduced heat production, body surface to body mass ratio, rapid metabolism, and thin subcutaneous fat layer are all maturational factors that might contribute to ineffective thermoregulation. 9. Which area of the body is responsible for thermoregulation? D. Hypothalamus Rationale: The hypothalamus functions as the body's thermostat, initiating physiologic mechanisms to balance heat loss and heat production. The hippocampus is within the brain's medial temporal lobe; it is responsible for processing long-term memory and emotional responses. The adrenal glands produce catecholamines and cortisol. The choroid plexus is responsible for producing cerebrospinal fluid in the ventricles of the brain. 10. The nurse is teaching the family members of an infant how to accurately measure a rectal temperature. What statement by the family member would indicate good understanding? C. "I will insert the thermometer about ½ inch." Rationale: Rectal thermometers should only be inserted approximately 1.5 cm (½ in) for an infant or 2.5 cm (1 in) for a child; inserting further risks damaging the rectal mucosa. Only the necessary area should be exposed when obtaining a rectal temperature; infants often urinate when their buttocks is completely exposed. A water-soluble, nongreasy, nonirritating lubricant should be used to lubricate the thermometer; petroleum jelly is greasy and not water soluble. The thermometer should not be removed until after the beep to ensure sufficient duration of measurement and accuracy.