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.)
A
B
C
None
None
None
The Correct Answer is B
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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Related Questions
Correct Answer is C
Explanation
A. A school-age child who has Haemophilus influenzae type b disease: Haemophilus influenzae type b typically requires droplet precautions, not contact precautions, unless the infection is invasive like meningitis.
B. An adolescent who has pneumonia: Pneumonia caused by most pathogens does not require contact precautions unless there are specific indications such as a highly contagious organism or a superimposed infection that mandates isolation.
C. An infant who has respiratory syncytial virus (RSV): RSV is highly contagious and spreads through respiratory secretions. Contact precautions are necessary to prevent transmission, especially in healthcare settings.
D. A preschooler who has tuberculosis: TB is transmitted through the air via respiratory droplets, so airborne precautions (including a negative pressure room and an N95 respirator) are necessary to prevent transmission.
Correct Answer is A
Explanation
A. Determine if the toddler has an allergy to iodine prior to the procedure: Cardiac catheterization typically involves the use of iodine-based contrast dye. It is crucial to determine if the toddler has an allergy to prevent any adverse reactions, during the procedure.
B. Check the toddler's vital signs once each hour following the procedure: After a cardiac catheterization, vital signs should be monitored more frequently than once per hour. Typically every 15-30 minutes during the first few hours following the procedure to detect any complications.
C. Give the toddler clear liquids prior to the procedure: Clear liquids are restricted before a procedure like cardiac catheterization, especially if sedation or anesthesia is involved. The child may be required to fast for several hours before the procedure to reduce the risk of aspiration.
D. Administer meperidine for pain immediately following the procedure: Meperidine is not recommended for pain management in children due to its potential for side effects, including seizures. Safer alternatives, like acetaminophen or morphine, are preferred
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