Answer to Question 1
B
In general, the height of the fever is not an indication of the seriousness of the illness. It is more important to note changes in the child's behavior. If a child has a low-grade temperature and acts sick, he or she should be assessed further. Feeling a child's forehead can give clues related to whether the child's temperature should be measured; if it has already been measured, this would be unnecessary because it does not give accurate information about the child's body temperature. Learning of other sick persons in the home will yield relevant information for the nurse to use in advising the parent, but it is not the best initial response. Although the height of the temperature is not an indication of the seriousness of the child's illness, it is incorrect to tell a parent to be unconcerned about temperatures less than 101 F.
Answer to Question 2
A
The method that is determined most appropriate for the child should be used consistentlythe same site and device to maintain consistency and allow reliable comparison and tracking of temperatures over time. Because of the risk of rectal perforation and the intrusive nature of the procedure, rectal temperatures are measured only when no other route can be used or when it is necessary to obtain a core body temperature. Oral temperatures can be used on most children older than 6 years of age but may be inaccurate because of oral intake, oral surgery, oxygen therapy, nebulizer treatments, or crying. The method of measuring temperature should be consistent, including at night.
Temperature and Color
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