A nurse is preparing a dose of insulin to give the client. Which action takes priority when preparing and administering this medication?
Double-check the dose with another RN before giving.
Insulin is a high-alert medication and the dosage must be checked with another RN before administering. All rights of medication administration should be adhered to. Insulin dosages come in units and the prescription is to administer a specific number of units, thus no calculations of dosages are needed. Insulin injections do not have to be witnessed. Insulin is not known for having adverse reactions, but it is always safe to ask the client if he or she has experienced any problems receiving insulin.
The nurse is administering a tube feeding to a child. The nurse aspirates the stomach contents as part of the process for checking placement of the tube. Which action is correct for the nurse to do with the aspirated stomach contents?
he nurse should measure and replace the residual stomach contents.
Measuring for residual is a way to determine gastric emptying time. Prior to each bolus feed or regularly during continuous feeds the nurse should aspirate some stomach contents, measure the amount, and then replace the contents if the volume does not exceed the parameter established by the health care provider. Not replacing can cause a decrease in the number of daily calories needed and can lead to electrolyte imbalances. The content does not need to be sent to the lab for analysis. If the nurse wishes to check tube placement that can be done at the bedside with a pH strip. If the stomach content is not going to replaced it should be discarded.
If a medication is being administered by the otic route, it will be administered in which way?
Warmed to room temperature and dropped into the ear
Otic means ear. Be sure that the ear drops are at room temperature. If necessary, roll the container between the palms of your hands to help warm the drops. Using cold ear drops can cause pain and possibly vertigo or vomitting when they reach the eardrum. If the medication were to be placed in the rectum the instructions would say "for rectal use only." A opthalmic drug would be placed in the eye. Medications in a syringe could be for injection or a liquid for oral use.
An infant is to have a scalp-vein intravenous infusion begun. What is an advantage of this insertion site?
The scalp veins are easily visualized.
Peripheral IVs can be inserted in neonates and infants. The scalp veins are easily visualized, being covered only by a thin layer of subcutaneous tissue. These veins do not have valves, so the device may be inserted in either direction, although the preference would be in the direction of blood flow. Unless the are area has been numbed before the procedure, the child will feel the pain of insertion. Infiltration can occur at any site a peripheral catheter has been inserted. Glucose can be absorbed from any vein from which it is infusing.
A health care provider has prescribed hydroxyurea 650 mg for a child diagnosed with sickle cell anemia. The child weighs 65 lb (29.5 kg). The normal recommended dose is 20 mg/kg/day. What action should the nurse take?
Contact the health care provider to lower the dose.
The nurse should perform the needed calculations to check the dosage is correct for the client. The nurse will use the client's weight in kilograms and multiply by the prescribed milligrams per day.
29.5 kg x 20 mg = 590 mg
The nurse has prepared an IM injection to give a 13-year-old child. After some searching, the nurse locates the child in the playroom in front of a video game. Which action is best for the nurse to take?
Inform the child that it is time for an injection. Explain why the injection is needed and have the child move to the treatment room.
Explaining the reason for a medication is appropriate for a 13-year-old child. The medication should not be given in the playroom. The playroom is a safe area for clients. Painful procedures should be done in a treatment room. Asking the child to take a break from the game sounds like the nurse is asking permission to give the medication. A child should not be given the opportunity to refuse a medicine.
Immediately following administering a medication by enteral tube, the nurse will:
flush the tube with water.
It is important to flush the tube to ensure all of the medication reaches the child's digestive tract and to prevent occlusion of the tube. Right (not left) side-lying position will aid in stomach emptying, although it was not specified that the enteral tube was located in the stomach. Elevating the head of the bed is done prior to placing material in the gastrointestinal tract. Checking for signs of nausea and vomiting is always important but not the immediately following nursing action in this situation.
A preschooler who is receiving gastrostomy feedings occasionally vomits following a feeding. When the parent describes the feeding process, what does the nurse note as the likely cause of the vomiting?
The mother does not check gastric residual prior to feedings.
Because gastric residual (amount left in the stomach from prior feeding) is not checked before feeding, there may be times the child's stomach is overfilled when the current nutritional material is added. Aspirating to measure residual would confirm this as well as provide data about how fast the child's stomach is emptying. The feeding plan may need to be modified. Not flushing the tube would not be related to vomiting. Using 25 minutes to administer a bolus feeding is an appropriate amount of time in most instances. A feeding pump would precisely control feeding rate and should not be the source of vomiting.
The nurse is caring for a 10-year-old girl with cystic fibrosis who receives pancreatic enzymes. Which comment by a parent demonstrates understanding of the instructions regarding the medication?
"I should give the enzymes before each meal or snack."
The enzymes are necessary for appropriate digestion and absorption of food and nutrients. There is no interaction between enzymes and antibiotics. Large, malodorous stools are a sign of no pancreatic enzyme activity. Pancreatic enzymes must be given each time the child eats, usually in smaller doses for snacks than for meals.
The nurse is showing the student nurse how to flush a pediatric client's peripherally inserted central catheter (PICC) line. The nurse prepares a 3-mL normal saline flush using a 5-mL syringe. The student asks the nurse why the flush was prepared this way. What is the most accurate response by the nurse?
"Using a larger-volume syringe exerts less pressure on the PICC line."
Using a larger-volume syringe (i.e., 5 mL or larger) exerts less pressure on the PICC, thereby reducing the risk of rupture.
A 4-year-old child is admitted to the hospital for surgery. Before the nurse administers medicine, the best way to identify the child would be to:
read the child's armband.
A child may answer to the wrong name or deny his or her identity to avoid an unpleasant situation or if scared of the unknown. If the child is avoiding the situation he or she may fail to answer. Using the child's nickname is okay in conversation but it is not a legal identification of the child. To verify the correct identity the nurse should verify the child's armband and the correct name with the child's caregiver. Bar code scanning the child's armband would also be a correct method of identification.
The nurse has finished completing a client education program for parents on proper medication administration to children. Which statement by a parent would indicate a need for further education?
"If my toddler won't swallow her medication, I will hold her nose until she has to swallow."
Proper medication administration includes placing a pill in applesauce or ice cream to help a child learn how to swallow it. When giving medications to an infant or small child, always have them in an upright position to avoid aspiration. Allowing a toddler or preschooler to squirt medication into their own mouth. You should never force medication into a child's mouth or pinch their nose. This increases the risk for aspiration and interferes with developing a trusting relationship.
A parent asks the nurse to explain what a PET scan is after learning that the child will be having a PET scan of the abdomen. What is the nurse's best response?
"It is similar to a CT scan but uses an injection of dye to help visualize the abdominal organs."
The CT scan procedure may include injection of an iodine-based radioisotope contrast medium. If this is necessary, the study may be referred to as positron emission tomography (PET) or single-photon emission computed tomography (SPECT). This is not a short procedure, and it is the nurse's responsibility to explain it to the child and family. Just giving the name of the procedure is not adequate teaching.
A child has returned to the unit after having a lumbar puncture. Which instructions are important for the nurse to provide the parents and child?
The child will need to remain flat to prevent a headache
After a lumbar puncture, remind children to remain quiet and with their head flat to help prevent a post dural puncture headache. Typically, children will not be fearful of staff nor will the child be up ambulating until later. The procedure should not need to be repeated in 24 hours.
A nurse is providing care for a child diagnosed with beta-thalassemia. The child requires a blood transfusion of packed red blood cells (PRBCs). The health care provider has prescribed a transfusion volume of 10 mL/kg. The child weighs 37 lb (16.8 kg). How many milliliters should the nurse infuse?
168
The nurse will use the client's weight in kilograms and multiply by the prescribed milliters/kilogram
16.8 kg × 10 mL PRBCs = 168 mL
A preschool child has been admitted to the hospital. Which prescription should the nurse question?
tap water enema 500 mL
Tap water is not used in enemas with children because, as it is not isotonic, it causes a rapid shift of fluid in body compartments, possibly leading to water intoxication. The nurse would want to question the health care provider about the prescription for a large tap water enema. The other prescriptions could be completed safely for a preschool child.
A neonate is to receive a hepatitis B vaccine within a few hours after birth. What is the best approach for the nurse to take when giving this medication?
Administer the medication in the neonate's vastus lateralis with a 25-gauge needle.
The vastus lateralis site is a safe choice for IM injections in a neonate. A 22- to 25-gauge needle is recommended for neonates, but the nurse must assess the neonate's size before determining needle size to use.The 25-gauge needle is recommended for neonates. The dorsogluteal site should not be used until school age. The deltoid muscle nor the dorsogluteal muscle is not a recommended IM site for neonates. These muscles should not be used until toddler age or older. The volume of the medication should not exceed 0.5 ml per injection until the child is preschool age.
A nurse is administering ear drops to a 7-year-old girl. What should the nurse do?
Pull the pinna of the ear up and back to straighten the external ear canal.
Remind the child ear drops can feel odd, as if someone were tickling the ear. Ear drops must always be used at room temperature or warmed slightly as cold fluid, such as medication taken from a refrigerator, does cause pain and may also cause severe vertigo as it touches the tympanic membrane. If the child is older than 2 years, pull the pinna of the ear up and back. Instill the specified number of drops into the ear canal. Hold the child's head in the sideways position while you count to 60 to ensure the medication fills the entire ear canal.
A health care provider has written several prescriptions for a 7-pound newborn with jaundice. Which prescription does the nurse need to question?
IV normal saline 20 mL/hour
IV fluids should be 2 mL/kg/hour, and this would calculate to 3.2 kg X 2 mL/hr = 6 mL/hour. The prescription for 20 mL/hour is too high for this newborn and would need to be questioned by the nurse. The other prescriptions are within reason.
The nurse is teaching a parent how to instill ophthalmic ointment to the child. Which comment by the parent would indicate the need for further teaching by the nurse?
"My other children can share the same eye ointment."
Eye medicine should be individually prescribed and not used by other children because if even the tip of the dropper or tube touches the conjunctival sac, it is contaminated with body fluid or microorganisms. This would require the nurse to teach about this. To instill an ophthalmic ointment, the nurse should apply a fine line of the ointment along the inside rim of the conjunctival sac, working from the inner to the outer eye canthus, being careful not to touch the tube to the eye. The nurse should always work from the inner to the outer canthus because if the eye is pus filled, applying medication under pressure toward the midline could force pus across to the other eye or down into the lacrimal duct.
The nurse is working to gain a preschooler's cooperation to swallow an oral medication. What would be the nurse's best approach?
ask if the child would like to take the medicine in a cup or through an oral syringe
The preschool age is when the child develops initiative. This is the sense that the child is helping. Thus, the nurse should allow the child ot participate in the medication task. The instructions and choices need to be simple. The nurse can ask if the preschooler would like to take the medicine in a cup or through an oral syringe. Medicine never should be compared to candy or any other foods. Doing so can present a safety problem if the child gets into the medication cabinet at home thinking he or she is getting candy. Children cannot be depended on to take medicine without supervision, so leaving the medication on the night stand would not only be ineffective it would also be dangerous. Bribing is ineffective. A preschooler is not going to do a task he or she does not like and the medication is needed to make the child well. The nurse should be gentle but firm in the administration of the medication.
The nurse is preparing to administer an intramuscular immunization to a 5-year-old child. What statement to the child is appropriate for inclusion in the preadministration period?
"This will help prevent you from getting sick."
When providing teaching to a child it is important to be open, honest and provide developmentally appropriate information. Explaining that this will prevent later illness is something a child can understand. Saying that pain may result if movement occurs is a scare tactic and counterproductive. Yes, this is an immunization but this is terminology that is too complex for a child. Using the word "shot" is scary for the child and should not avoided if possible.
A child is receiving intravenous fluids for dehydration. The nurse notes coarse breath sounds and increased pulse and blood pressure. What does the nurse do first?
Discontinue the IV infusion.
Signs of fluid overload are those of congestive heart failure and include coarse breath sounds, increased pulse rate, and increased blood pressure. These are not symptoms of extravasation because this would be swelling of fluid around the IV site. The nurse would need to stop the IV infusion, then assess weight, intake, and output. The nurse would then contact the health care provider.
An infant is scheduled to have a painful procedure performed. Which nursing action provides the best support for the parents and infant?
Allow the parents to hold the infant during the procedure.
It is important for the nurse to advocate for parents to remain in the procedure room to provide support to the infant. The parent may choose to hold the infant during a painful procedure, but it is best that the parent not restrain the procedure. Their role should be supportive and comforting, not one that causes pain. Having the parents remain outside the room leaves the infant without needed support. Infants experience pain but express it differently than adults.
A nurse is educating the parents how to administer daily oral medication to their 5-year-old boy. Which response indicates a need for further teaching?
"He needs to take his medicine or he will lose a privilege."
The nurse should emphasize that the parents should never threaten the child in order to make him take his medication. It is more appropriate to develop a cooperative approach that will elicit the child's cooperation since he needs ongoing, daily medication. The other statements are correct.
Prior to administering an intermittent tube feeding, which action should be performed?
Assess tube placement.
Checking for tube placement is a priority before administering any intermittent tube feeding and periodically during continuous tube feedings, regardless of the type of tube being used.
Parents asks the nurse why their premature infant is receiving a feeding through the mouth rather than the nose. What is the best explanation by the nurse?
Newborns are obligate nose breathers so nasogastric may obstruct their breathing.
Whether enteral catheters should be passed through the nares or the mouth is controversial. Because newborns are obligate nasal breathers, passing a catheter through the nose may obstruct their breathing space, and repeated insertion of a nasal gastric tube can cause inflammation and obstruction of the nose; thus most tubes are inserted orally in small infants. Orogastric insertion can also decrease the possibility of striking the vagal nerve in the back of the throat and causing bradycardia, whereas nasogastric tubes increase the possibility of striking the vagal nerve.
The nurse has been teaching an adolescent about the treatment for hypothyroidism. Which outcome indicates that the teaching has been successful?
The client states understanding that this is a lifetime medication.
Treatment for hypothyroidism is typically for life because the thyroid is no longer fully functioning. Thyroid replacement medication should be taken on an empty stomach. There is no need to restrict athletic activities, and follow-up is going to be needed more frequently than yearly at the beginning of treatment.
Which assessment is most important for determining an accurate dose of a pediatric medication?
Body surface area
Body surface area (BSA) is the most accurate measure for dosing medications for children. In pediatrics, there are no standard amounts of a drug given per age; rather, dosage is based on weight using an established amount of the drug per body weight. Body mass index is not considered when determining pediatric medication dosing.
To give eardrops to a 4-year-old child, what would be the best technique to use
Pull the pinna of the ear up and back.
Pulling the pinna upward and back straightens the ear canal in the child older than 3 years of age. To administer otic drops to a child younger than 3 years, the pinna would be pulled downward and back. Pressing the pinna of the ear forward or downward would occlude the ear canal.
Included in the nursing care plan for the child receiving total parenteral nutrition (TPN) will be which intervention?
Regularly monitoring the child's blood glucose
Monitoring the blood glucose is important with TPN since the glucose content of the solution is high and can cause hyperglycemia. The need for a stool softener would be determined on an individual basis. Children receiving TPN may or may not be taking food and fluids orally. The catheter delivering the TPN solutions will be centrally placed to accommodate the concentrated TPN solution (larger vessel with more rapid blood flow).
The nurse knows that which situation will prevent an adolescent from having a magnetic resonance image (MRI)?
metal dental braces
Because metal may deflect the magnetic waves, children with a metal prosthesis or metal dental braces are poor candidates for the procedure. Hairpins and eye makeup (which often has a metallic base), watches, or other jewelry should be removed.
The child weighs 27 kg. Using the following formula, calculate how many milliliters of intravenous fluids should be administered to the child in a 24-hour period. Record your answer using a whole number.
Formula:
100 milliliters per kilogram of body weight for the first 10
kilograms
50 milliliters per kilogram of body weight for the next 10 kilograms
20 milliliters per kilogram of body weight for the remainder of body weight in kilograms
1640
(First 10 kg) 10 kg x 100 mL/kg = 1,000 mL (Second 10 kg) 10 kg x 50 mL/kg = 500 mL (remaining kilograms of body weight) 7 kg x 20 mL/kg = 140 mL 1,000 + 500 + 140 = 1,640 mL
The nurse is calculating the urinary output for the infant. The infant's diaper weighed 40 grams prior to placing the diaper on the infant. After removal of the wet diaper, the diaper weighed 75 grams. How many milliliters of urine can the nurse document as urinary output? Record your answer using a whole number.
35
The diaper must be weighed before being placed on the infant and after removal to determine urinary output. For each 1 gram of increased weight, this is the equivalent of 1 milliliter of fluid. 75 grams - 40 grams = 35 grams = 35 mL
A child is being discharged from the hospital and the nurse has completed discharge teaching regarding prescribed liquid medications. Which comments by the parent demonstrates understanding of discharge instructions for safe medication administration? Select all that apply
~"I need to make sure to use the medicine dropper the pharmacy gives me instead of the syringe I
use for my B12 injections."
~"I shouldn't use a liquid dropper from my kitchen because it may be a different measurement than one from the pharmacy."
~"I will be sure to not give too much of the liquid medication at one time."
Only droppers given by the pharmacy for the specific medication should be used. Different syringes may have different measurements than pediatric oral syringes. Mixing medication syringes is avoided if a dropper is packaged with a certain medication since the drop size may vary from one dropper to another. Giving small amounts of liquid avoids aspiration. Pinching the child's nose increases the risk for aspiration and interferes with the development of a trusting relationship.
A 4-year-old child is being prepared to undergo a bronchoscopy to remove an aspirated pea. The nurse knows that the parents need reteaching based on which statement?
"We will be able to take our child home immediately after the procedure is completed."
The child will not leave immediately. Procedural complications are not common but may include compromise to the airway such as hemorrhage, pneumothorax, and airway edema. After the procedure, the nurse will need to continue to assess the child's respiratory function and airway patency. Postprocedure complications may include bronchospasm, stridor, desaturation, or respiratory distress. The nurse will observe children carefully the first time they drink after the procedure to assess that their gag reflex is intact and they do not choke. All of the other options are correct.
The nurse is preparing to administer an oral dose of metoclopramide to a 5-year-old child who weighs 40 lb (18.2 kg). The prescription reads metoclopramide 0.8 mg/kg/day to be given in 4 oral doses. How many milligrams of metoclopramide would the nurse give per dose?
3.65 mg per dose
To calculate the does, use the client's weight in kilograms. Multiply 0.8 mg by 18.2 kg, which equals 14.6 mg per day for the client's weight. Then, divide 14.6 mg by 4, the number of doses per day day, to arrive at 3.65 mg per dose.
A nurse has just given otic medication instructions to the parents of a 12-year-old child. Which statement would indicate that the parents need further education concerning the medication
"I will pull the outer ear down and back before administering the medication."
The proper technique to instill ear drops in a child older than age 3 involves pulling the pinna up and back. Otic medication should not be administered if it is cold. Cold medication may cause discomfort and produce vomiting or vertigo in the child. If an otic medication must be refrigerated, it should be warmed to room temperature in the palms of the hands. Proper otic administration technique involves holding the dropper 0.5 in (1.25 cm) above the ear canal and being careful not to touch the dropper to the ear to prevent contamination of the dropper with microorganisms. For children young than 3, the parent would pull the pinna down and back.
A 5-year-old boy is receiving an analgesic intravenously while in the hospital. What should the nurse do to determine whether the drug is being properly excreted from this child?
Monitor the child's fluid intake and output
Monitoring intake and output is important in children receiving drugs to be certain urine excretion or an outlet for drug metabolites is adequate. The other interventions listed are not typically used to determine whether drug excretion is occurring.
The nurse is assessing a child who is receiving TPN. The nurse determines the TPN bag was hung 24 hours ago. What initial action by the nurse is indicated?
Hang a new bag of TPN.
TPN bags should not hang over 24 hours. The nurse should discontinue the current bag and hang a new one. There is no need to notify the physician. The rate of the TPN should never be changed without a physician's order.
A child with gastroenteritis has been unable to keep oral medication down. What nursing intervention would be appropriate for this client?
Request an intravenous form of the medication.
Absorption is the transfer of the drug from its point of entry into the bloodstream, and vomiting and diarrhea interfere with absorption because the drug does not remain in the gastrointestinal tract long enough to be absorbed. Distribution is not affected by vomiting and diarrhea, as it involves movement of the drug through the bloodstream. Metabolism involves conversion of the drug into an active or inactive form, and is unaffected by gastroenteritis. Excretion is the elimination of the drug from the body, usually through the kidneys. This is also unaffected by vomiting and diarrhea
The nurse is administering an oral liquid medication to a 5-year-old child. What would be the most appropriate for the nurse to do when administering this medication?
Let the child hold the medication cup.
Droppers and oral syringes can be used to administer medications to infants and young children. Medication cups and spoons can be used to administer liquid medications to the older child. The child can hold the medication cup and drink the liquid medication. Depending upon the age of the child the child may still prefer to take liquid medications via the syringe. It makes taking the medication fun when the child can squirt it into the mouth by him- or herself. The child who is lying down when being given medications should have the head of the bed elevated to at least 45 degrees .A 5-year-old child does not need to be restrained for medication administration.
The site most often used when administering a medication using the intradermal route is the:
forearm.
Intradermal injections deposit medications just under the epidermis. They are most often used for tuberculosis screening and allergy testing. The forearm is the site most often used. The anterior thigh, lateral upper arms, and abdomen are the preferred sites for subcutaneous administration. The deltoid, vastus lateralis and the ventrogluteal are the preferred sited for intramuscular injections.
The nurse is caring for a child who weighs 31 kg. A medication is ordered for this child with a dosage range of 20 to 40 mg per kg of body weight per dose. Which dosage would be appropriate for the nurse to administer to this child in one dose?
1,000 mg per dose
If a dosage range of 20 to 40 mg per kg of body weight is a safe dosage range, and a child weighs 31 kg, the low dose of this medication would be 31 X 20 = 620. The high dose of this medication would be 31 X 40 = 1,240. Therefore, a dose of 1,000 mg per dose would be appropriate.
The child weighs 47 pounds. How many kilograms does the child weigh? Record your answer using one decimal place.
21.4
There are 2.2 lb per kg. 47 lb x 1 kg/2.2 pounds = 21.363636 kg. When rounded to the tenths place, the answer is 21.4 kg.
The nurse is caring for a 4-year-old who requires a venipuncture. To prepare the child for the procedure, which explanation is most appropriate?
"The doctor will look at your blood to see why you are sick."
The nurse should provide a description of and reason for the procedure in age-appropriate language. The nurse should avoid the use of terms such as culture or strep throat as it is not age appropriate for a 4-year-old. The nurse should also avoid confusing terms like "take your blood" that might be interpreted literally.
The pediatric nurse recognizes that what statement is true regarding medications administered via the intravenous route?
Giving medications through the intravenous route is less traumatic than other routes.
Delivering medications intravenously is actually less traumatic than administering multiple intramuscular injections.
The nurse is educating the parents of a 5-month-old on how to administer an oral antibiotic. Which response indicates a need for further teaching?
"We can mix the antibiotics into his formula or food."
Never mix a medication with formula or food. The child may associate the bitter taste with the food and later refuse to eat it.
The nurse is assessing the aspirate of a gavage feeding tube to confirm placement. Which assessment finding indicates intestinal placement?
Yellow aspirate
Yellow or bile-stained aspirate indicates intestinal placement. Clean, tan, or green aspirate indicates gastric placement
The nurse is preparing to administer a PO medication to a 6-year-old in the hospital for an exacerbation of asthma. The nurse notes that the child is due for an oral dose of lansoprazole in 1 hour. What is the most important action for the nurse to take before administering this medication to the client?
Clarify the order, since there is no apparent link between the client's diagnosis and the medication.
There is no clear link between this client's diagnosis and the lansoprazole administration. The nurse should clarify a medication order that does not have a clear link to the client's diagnosis before giving the medication. Asking the mother how she usually gives the medication is a good idea; however, it is not the priority nursing action in this scenario. Parental permission is not required to administer this medication. Consent to treat is signed upon admission to the hospital.
The nurse is providing discharge education to the parents of a 2-year-old who will be taking amoxicillin orally at home. The nurse would include which statement in the teaching?
"Use a dosing cap to measure the dosage."
When talking to parents about giving medicine, stress that if a medicine comes supplied with a dosing cap, it is best to use that to measure the correct dose (Pham et al., 2011). If there is no dosing cap, then an oral medicine syringe or dropper are the next best methods to measure liquid medicine because kitchen teaspoons are rarely exactly 5 ml. Antibiotics need to be taken for the full course, not until symptoms subside. Mixing the medication with a drink or in food makes it difficult to determine how much the child has taken if the child refuses to finish it all. Amoxicillin comes in a liquid form, so crushing the pills is not appropriate.
A pediatric nurse is mentoring a new graduate nurse. Which action by the new nurse would require intervention by the pediatric nurse?
taking a rectal temperature on a newborn
The mentor would need to intervene if a new nurse was taking rectal temperatures. Taking a temperature rectally increases the risk of damaging the infant's fragile rectal mucosa with a thermometer. The American Academy of Pediatrics (2013) put forth a position statement that "temperatures taken with temporal artery thermometers correlated with rectal temperatures better than axillary and tympanic membrane thermometry." The other actions are all appropriate nursing interventions.
A nurse is requesting that the unlicensed assistive personnel (UAP) take vital signs on a group of children in the pediatric clinic. Which child does not need blood pressure assessed?
2-year-old for well-child check
Beginning at 3 years of age, children should have their blood pressure measured at every office visit (NIH, 2005). The other children are over 3, so they should have their blood pressure measured.