PEDS--Oral Temp

Notes

Inaccurate temperature measurement can result in serious errors in diagnosis and treatment. 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 about to assess an oral temperature on a child. What would be important for the nurse to consider?

A. Oxygen therapy can affect the reliability of an oral temperature reading. Rationale: Oxygen therapy, mouth breathing, and the recent intake of hot or cold food or liquids can affect the reliability of an oral temperature reading. Oral temperature measurement is recommended when a child can follow instructions and hold a thermometer under the tongue; therefore, it is not appropriate for a toddler. Oral temperature measurements are not affected by ambient temperature changes.

5. When obtaining an oral temperature measurement in a child, what would be important for the nurse to do?

A. Place the thermometer under the tongue, slightly off the midline in the sublingual pocket. Rationale: Placing the oral thermometer under the tongue, slightly off the midline in the sublingual pocket ensures the most accurate measurement. Waiting several minutes after oral fluids also helps to ensure an accurate measurement. Oral temperatures should be obtained by the nurse to ensure proper technique and accuracy. Another route should be considered for a child with respiratory distress because the child may have difficulty closing the mouth around the thermometer, and the accuracy may be affected by mouth breathing.

4. 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.

8. The nurse is teaching the family members of a school-age child how to accurately measure an oral temperature. What statement by the family member would indicate good understanding?

B. "I will avoid taking the temperature after eating or drinking." Rationale: It is important to avoid hot or cold food or liquids before measuring an oral temperature so the reading can be accurate. The thermometer should not be removed until after the beep to ensure sufficient duration of measurement and accuracy. Although it is a good strategy to involve children in their own care, it is inappropriate to ask the child to hold or help position the thermometer because this risks an inaccurate measurement. The tip of the thermometer should be held under the tongue and to the side.

9. Through which mechanism do infants maintain body temperature?

B. 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.

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

C. Insufficient 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.

2. After the nurse measures a child's oral temperature, what would be important to document?

C. Method of temperature measurement Rationale: Documentation after measuring a child's temperature must include the method used. The nurse must ensure that the thermometer is left in place long enough to obtain an accurate temperature (e.g., audible signal), but does not need to document how long the thermometer was in place. The child's position should not influence the accuracy of an oral temperature measurement. Ambient temperature does not affect oral temperature measurement and does not need to be documented.

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

C. Retake the oral temperature to verify accuracy. Rationale: The child's clinical condition should always be assessed when a temperature measurement is obtained, and the oral 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 oral temperature and after an alternative method is used. Once a reliable result is obtained, the practitioner should be notified.

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

D. 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 oxygen administration, mouth breathing, and the intake of hot or cold liquids or foods.

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

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.