Documenting an axillary temperature for a 3-year-old child
Obtaining a rectal thermometer probe for a child with diarrhea
Attempting to take an oral temperature on a child who is receiving oxygen
Rectal measurement remains the clinical gold standard for the precise diagnosis of fever in infants and children compared with other methods. However, this procedure is more invasive and is contraindicated for infants less than 1 month old, children with recent rectal surgery, children with diarrhea or anorectal lesions, and children receiving chemotherapy. An oral temperature is appropriate for a 12-year-old child who has not had anything hot or cold to eat or drink recently. Oral temperatures are considered the standard for temperature measurement but are contraindicated in children who have an altered level of consciousness, are receiving oxygen, are mouth breathing, are experiencing mucositis, had recent oral surgery or trauma, or are under 5 years old. Axillary temperatures are inconsistent and insensitive in infants and children older than 1 month. The charge nurse should intervene to assess if a definitive temperature is needed. The temperature may need to be taken by a different route. For infants less than 1 month old, the American Academy of Pediatrics (2001) recommends axillary temperatures. An axillary temperature is appropriate for a 3-week-old child.