A nurse is collecting data from an infant. Which of the following sites is the most reliable location to check the infant's pulse?
Apical
Dorsalis pedis
Temporal
Carotid
The Correct Answer is A
A. Apical:
The apical pulse is the most reliable location to assess the pulse in infants. It is located at the apex of the heart, which is typically found at the fifth intercostal space at the midclavicular line. Assessing the apical pulse allows for a direct measure of the heart rate and rhythm, which is especially important in infants to evaluate cardiac function accurately. The apical pulse is commonly assessed using a stethoscope placed at the point of maximum impulse (PMI) on the chest.
B. Dorsalis pedis:
The dorsalis pedis pulse is located on the top of the foot, typically in the region between the first and second metatarsal bones. While the dorsalis pedis pulse can be palpated in older children and adults, it may be difficult to palpate accurately in infants, especially those with smaller or more delicate feet. Therefore, it is not the preferred site for pulse assessment in infants.
C. Temporal:
The temporal pulse is located on the side of the head, just above the ear. While the temporal pulse can be palpated in some individuals, it is not typically used to assess the pulse in infants. Palpating the temporal pulse in infants may be more challenging and less reliable compared to other pulse sites, especially given the smaller size of the temporal artery in infants.
D. Carotid:
The carotid pulse is located in the neck, alongside the trachea, and can be palpated by gently pressing the fingers against the carotid artery. While the carotid pulse is easily palpable in adults and older children, it is not typically the preferred site for pulse assessment in infants. Palpating the carotid pulse in infants carries a risk of injury to the delicate structures in the neck and may not provide an accurate representation of the pulse rate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
To calculate the appropriate dose of Theophylline for the child weighing 4.69 kg:
Dose = Weight (kg) × Dose (mg/kg)
Dose = 4.69 kg × 4 mg/kg
Dose = 18.76 mg
So, the appropriate dose is approximately 18.7 mg.
Correct Answer is A
Explanation
A. Give the child a stuffed animal: Providing a comforting item like a stuffed animal can help the child feel more secure and may offer some comfort during the parent's absence. This option is appropriate as it addresses the child's emotional needs.
B. Inform the child that her parent will be back in 2 hours: While it's helpful to provide reassurance to the child, a 2-year-old may not fully understand the concept of time, and telling them that their parent will return in 2 hours may not effectively alleviate their distress. This option may not be as immediately comforting as providing a tangible source of comfort.
C. Call the parent to return to the child's room: If possible, having the parent return to the child's room can provide the most direct comfort and reassurance to the child during a tantrum. However, it may not always be feasible for the parent to return immediately, especially if they are occupied or attending to other responsibilities.
D. Leave the child alone in the room for 5 minutes: Leaving the child alone during a tantrum can exacerbate feelings of distress and abandonment, potentially escalating the situation further. It's essential to provide support and reassurance to the child during moments of distress rather than leaving them alone.
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