A nurse is caring for a child who was admitted with suspected rheumatic fever. The provider prescribes an antistreptolysin O (ASO) titer. The parent asks the nurse about the purpose of the test. Which of the following responses should the nurse make?

Choice A: This action is not appropriate, as it may cause more harm than good to separate the child from the parents without sufficient evidence or reason. Separating the child from the parents can cause fear, anxiety, or resentment in both parties and may interfere with establishing rapport and trust. The nurse should only separate the child from the parents if there is an immediate threat or danger to the child's safety.

Choice B: This action is premature, as it may violate confidentiality and ethical principles to report suspected abuse to the authorities without sufficient evidence or reason. Reporting suspected abuse to the authorities can have serious legal and social consequences for both parties and may escalate or worsen the situation. The nurse should only report suspected abuse to the authorities if there is clear evidence or indication of abuse or if mandated by law.

Choice C: This action is irrelevant, as it may not address the issue or help resolve it to ask a psychiatrist to talk with the parents without sufficient evidence or reason. Asking a psychiatrist to talk with the parents can imply that they have mental health problems or that they are guilty of abuse, which can cause stigma, anger, or denial. The nurse should only ask a psychiatrist to talk with the parents if there is evidence or indication of mental health problems or if requested by them.

Choice D: This action is appropriate, as it can help determine whether there is any evidence or reason to suspect abuse or not. Obtaining a detailed history can provide information about how, when, where, and why the bruises occurred and whether they are consistent with accidental or intentional injury. The nurse should obtain a detailed history from both parties separately and in a nonjudgmental and supportive manner.

Choice A reason: This choice is incorrect because the radial artery is not an ideal site to assess the heart rate in an infant. The radial artery is located on the thumb side of the wrist, and it can be palpated by placing two fingers over it. It may be used for adults or older children who have a strong pulse, but it may be difficult to locate or feel in an infant who has a small or weak pulse.

Choice B reason: This choice is incorrect because the carotid artery is not an ideal site to assess the heart rate in an infant. The carotid artery is located on either side of the neck, and it can be palpated by placing two fingers over it. It may be used for adults or older children who have a cardiac arrest or shock, but it may be risky to use in an infant who has a fragile neck or airway.

Choice C reason: This choice is incorrect because the brachial artery is not an ideal site to assess the heart rate in an infant. The brachial artery is located on the inner side of the upper arm, and it can be palpated by placing two fingers over it. It may be used for infants or young children who have a blood pressure measurement, but it may be uncomfortable or inaccurate to use for a heart rate assessment.

Choice D reason: This choice is correct because the apex of the heart is an ideal site to assess the heart rate in an infant. The apex of the heart is located at the fifth intercostal space on the left midclavicular line, and it can be auscultated by placing a stethoscope over it. It may be used for infants or young children who have a regular and strong heartbeat, and it may provide the most accurate measurement of the heart rate.