An infant’s axillary temperature is 35.9C (96.6F). The priority nursing action is to:
A.
chart the normal axillary temperature.
B.
recheck the infant’s temperature rectally.
C.
place the infant in a radiant warmer.
D.
have the mother breastfeed the infant.
The correct answer is:
C. Place the infant in a radiant warmer.
Explanation: An axillary temperature of 35.9°C (96.6°F) in an infant is below the normal range and indicates hypothermia. Hypothermia in infants can lead to complications such as respiratory distress, hypoglycemia, and metabolic acidosis. The priority nursing action is to warm the infant safely and effectively. Placing the infant in a radiant warmer will help raise the infant’s body temperature to a normal level.
The other options are less appropriate in this situation:
- A. Chart the normal axillary temperature: This temperature is not normal for an infant and should not be documented as such.
- B. Recheck the infant’s temperature rectally: While it’s important to confirm an abnormal temperature, the priority is to address the hypothermia immediately rather than waiting for another temperature reading.
- D. Have the mother breastfeed the infant: While breastfeeding is important, it is not the immediate priority in addressing the infant’s low body temperature. The infant should first be warmed before other actions are taken.