A nurse is collecting data from an infant.
Which of the following sites is the most reliable location to check the infant’s pulse?
Carotid.
Dorsalis pedis.
Temporal.
Apical.
The Correct Answer is D
Choice A rationale
The carotid pulse is not the most reliable location to check an infant’s pulse because it can be difficult to locate and can cause discomfort to the infant.
Choice B rationale
The dorsalis pedis pulse is not the most reliable location to check an infant’s pulse because it can be difficult to locate in small infants.
Choice C rationale
The temporal pulse is not the most reliable location to check an infant’s pulse because it can be affected by external factors such as temperature and can be difficult to locate in small infants.
Choice D rationale
The apical pulse is the most reliable location to check an infant’s pulse. It is located at the apex of the heart and can be easily heard using a stethoscope. It provides the most accurate assessment of the heart rate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
A bulging fontanel is a common sign of increased intracranial pressure (ICP) in infants. The fontanels, or soft spots on an infant’s head, allow for brain growth. When there is increased pressure, as in conditions that cause increased ICP, it can cause the fontanels to bulge outwards.
Choice B rationale
Insomnia is not typically associated with increased ICP in infants. Changes in consciousness, such as irritability or lethargy, may be seen, but these are not the same as insomnia.
Choice C rationale
A low-pitched cry is not typically associated with increased ICP in infants. Changes in cry might occur, but they are not specific to increased ICP4.
Choice D rationale
A positive Babinski reflex is normal in infants up to about 12 months of age. It is not specifically associated with increased ICP4.
Correct Answer is B
Explanation
Choice A rationale
Feeding an infant with spina bifida through an NG tube may not be necessary unless the child has specific feeding difficulties or other health issues. Spina bifida does not typically affect a child’s ability to eat or swallow.
Choice B rationale
Placing an infant with spina bifida in a prone position can help protect and care for the lesion on their back. It can also help prevent pressure sores and promote comfort.
Choice C rationale
Covering the infant’s lesion with a dry cloth is not typically recommended. The lesion should be kept clean and moist to promote healing and prevent infection.
Choice D rationale
While physical therapy and exercises can be beneficial for children with spina bifida, performing range-of-motion exercises to the infant’s hips may not be necessary unless specifically recommended by a healthcare provider.
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