PEDS--Temp Axillary

10. What area of the body is responsible for thermoregulation?

A. 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.

3. The nurse is preparing to measure an axillary temperature on a child. What would be important for the nurse to consider before assessing the child's temperature?

A. Keeping the child's arm close to the chest increases accuracy. Rationale: Keeping the child's arm close to the chest and holding the thermometer until the reading is complete helps ensure an accurate measurement and decreases the effect of environmental temperature, which can influence the temperature accuracy. Axillary temperatures are acceptable for children of many ages as long as proper technique is used. Using a combination of temperature measurement techniques in children is acceptable.

7. The nurse is about to assess an axillary temperature on an infant using an electronic (multiple-use) thermometer. What would be important for the nurse to consider?

A. The blue thermometer probe is used for oral and axillary temperatures. Rationale: When using an electronic (multiple-use) thermometer, the blue probe is used for oral and axillary temperatures and the red probe is used for rectal temperatures. The red probe should not be used for oral and axillary temperatures even if the blue probe is broken.

1. The nurse is planning care for a school-age child with leukemia. The child is receiving parenteral nutrition because of malnutrition, persistent stomatitis, and an inability to take in adequate calories by the enteral route. What should the nurse know regarding taking this child's temperature?

A. The condition of the axillary skin must be assessed before an axillary temperature measurement is obtained. Rationale: The skin of the axilla should be assessed before an axillary temperature is measured; if the child has skin breakdown, the site should not be used. Rectal temperature measurement in a school-age child would be traumatic, embarrassing, and may be contraindicated in a child with leukemia. Axillary temperature measurement is influenced by ambient temperature; therefore, increasing the room temperature and layering blankets could artificially inflate the temperature measurement. The nurse should hold the temperature probe to ensure proper technique and for safety and should never leave the child alone when taking a temperature measurement.

6. Through what mechanism do infants maintain body temperature?

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.

9. The nurse is teaching the family members of a toddler how to accurately measure an axillary temperature. What statement by the family member would indicate good understanding?

C. "I will wait for the thermometer to beep." Rationale: Waiting for the thermometer to beep ensures sufficient duration of measurement. Since the armpit should be dry for accurate measurement, checking the axillary temperature during a bath would be inappropriate. Although it is a good strategy to involve children in their own care, it is inappropriate to have the toddler help position the thermometer because this risks an inaccurate measurement. The tip of the thermometer should be placed in the apex of the axilla (not below it) for accurate measurement.

8. Which maturational factor would the nurse recognize as contributing to ineffective thermoregulation in infants and children?

C. Body surface to mass ratio Rationale: Maturational factors affecting thermoregulation in infants and children include reduced heat production, body surface to body mass ratio, rapid metabolism, and a thin subcutaneous fat layer. Skin moisture, excessive or insufficient clothing, and inadequate heat or humidity are all environmental factors that might contribute to ineffective thermoregulation.

4. The nurse obtains an abnormally low axillary temperature measurement on a child who appears well. What would be the next appropriate action by the nurse?

C. Retake the axillary temperature to verify accuracy. Rationale: The child's clinical condition should always be assessed when a temperature measurement is obtained, and the axillary temperature should be confirmed for accuracy. Because an inaccurate temperature reading may incorrectly influence the treatment plan, obtaining an accurate reading should not be delayed. Interventions for treating an abnormal temperature should begin after verification of the abnormal axillary temperature and after an alternative method is used. Once a reliable result is obtained, the practitioner should be notified.

2. The nurse preceptor is educating the graduate nurse about processes that influence body temperature in children. What response from the graduate nurse indicates that the teaching was effective?

D. "Low metabolism can cause a decrease in body temperature." Rationale: A low metabolic rate can result in a decreased body temperature, whereas a high metabolic rate can result in an increased body temperature. The process of digestion does not typically affect body temperature. Shivering can increase, not decrease, body temperature. Increased, not decreased, thyroid activity would result in an increase in body temperature.

Notes

Do not use axillary temperature measurement if the skin in the axilla is not intact. Inaccurate temperature measurement can result in serious errors in diagnosis and treatment. Axillary temperature readings cannot be relied upon to detect a fever. Do not use an electronic thermometer intended for multiple children for a child who needs protective isolation; use a single-use digital thermometer instead.

5. What site is considered the gold standard for pediatric temperature measurement in the critically ill or unstable child?

Rectal Rationale: Rectal temperature measurement is considered the gold standard in critically ill or unstable children because it is least influenced by the environment. Temporal and axillary measurements are often used because they are quick and noninvasive, but they are not considered the gold standard because of the influence of ambient temperature. Oral measurement is also frequently used, but it is easily influenced by the intake of hot or cold liquids or foods.