A nurse is collecting data from a 1-week-old infant who is scheduled for a cardiac catheterization. Which of the following locations should the nurse palpate in order to identify the infant's point of maximal impulse? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)
The Correct Answer is "{\"xRanges\":[207.828125,247.828125],\"yRanges\":[145,185]}"
Point A: Represents the third intercostal space at the right sternal border, which corresponds anatomically to the aortic valve area. This is a key auscultation site used during cardiac assessment to listen for murmurs and abnormalities related to the aortic valve. It is not used for palpation.
Point B: Fourth intercostal space at the left midclavicular line and is the correct location for palpating the point of maximal impulse (PMI) in infants and young children. In this age group, the PMI is typically found here due to the more horizontal position of the heart in the chest.
Point C: This location is at the 2nd or 3rd intercostal space, which is too high to assess the PMI in an infant. This area is used more for evaluating pulmonic valve sounds, not the apex of the heart.
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Correct Answer is C
Explanation
A. "It measures the amount of oxygen circulating in the blood." The HbA1c test does not measure oxygen levels. Oxygen levels in the blood are measured through tests like pulse oximetry or arterial blood gas tests.
B. "It measures the amount of immature white blood cells." The HbA1c test measures the average blood glucose levels over the past 2-3 months, not white blood cells. The immature white blood cell count is assessed through a different blood test (e.g., a complete blood count).
C. "It measures the glucose circulating in the blood stream." The HbA1c test reflects the average blood glucose levels over the past 2-3 months by measuring the percentage of hemoglobin that has glucose attached to it.
D. "It measures the amount of red blood cells." The HbA1c test does not measure the number of red blood cells; it measures the percentage of hemoglobin in red blood cells that is bound to glucose, which helps assess blood sugar control over time.
Correct Answer is C
Explanation
A. Skin condition: The fine rash noted on the chest and abdomen is not itchy, which is a common finding in infectious mononucleosis. It is not a primary concern unless it worsens or develops other characteristics, but it is not the most urgent issue to report.
B. Temperature: The client's temperature of 38.2°C (100.8°F) is slightly elevated, which is typical in infectious mononucleosis. It is within the expected range for the condition, and the prescribed acetaminophen should help manage the fever.
C. Pain level: The client reports significant pain in the left upper quadrant (rated 8 on a scale of 0 to 10) that worsens with palpation. This could indicate splenic involvement, which is a serious complication of mononucleosis, as the spleen can become enlarged and rupture.
D. Intake: The client is drinking at least 8 cups of water per day and eating about 60% of meals, which is an adequate fluid intake for the current state. Although not perfect, the intake is not a primary concern at this time compared to the pain level.
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