Question

a nurse is planning to obtain a rectal temperature from a toddler. which of the following actions should the nurse take?

• insert the tip of the thermometer 5 cm (2 in) into the rectum.
• place the child in prone position.
• stabilize the thermometer at the distal end.
• direct the tip of the thermometer toward the spine during insertion.

Explanation:

To obtain a rectal temperature in a toddler, the correct procedure for inserting the thermometer:

• For a toddler, the thermometer tip is inserted about 2.5 cm (1 in), not 5 cm, so the first option is incorrect.
• The child should be placed in a side - lying (lateral) or prone position? Wait, no, the correct position for rectal temp in a toddler is usually side - lying or prone? Wait, no, actually, when taking rectal temperature in a toddler, the correct insertion direction is toward the spine (sacrum) to follow the natural curve of the rectum. Let's analyze each option:
• Option 1: Inserting 5 cm is too much for a toddler (should be ~2.5 cm), so wrong.
• Option 2: Prone position is not the standard; lateral (side - lying) is more common, but even if prone, the key is the insertion direction.
• Option 3: Stabilizing at the distal end (the end away from the tip) is not correct; you should hold the thermometer at the proximal end near the tip to insert and stabilize.
• Option 4: Directing the tip toward the spine (sacrum) follows the curve of the rectum, which is the correct technique to prevent injury and ensure accurate measurement.

Answer:

D. Direct the tip of the thermometer toward the spine during insertion