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 C
Explanation
Choice A rationale
While providing age-appropriate stimulation is important for a newborn’s development, it is not the priority nursing goal for a newborn with a myelomeningocele. The immediate focus should be on preventing infection and injury to the exposed neural tissue.
Choice B rationale
Promoting maternal-infant bonding is important, but it is not the priority nursing goal for a newborn with a myelomeningocele. The immediate focus should be on preventing infection and injury to the exposed neural tissue.
Choice C rationale
Maintaining the integrity of the sac is the priority nursing goal for a newborn with a myelomeningocele. The sac contains exposed neural tissue that is at risk for injury and infection. Protecting the sac from damage and keeping it clean and moist until surgery can help prevent complications.
Choice D rationale
While educating the parents about the defect is an important part of nursing care, it is not the priority nursing goal for a newborn with a myelomeningocele. The immediate focus should be on preventing infection and injury to the exposed neural tissue.
Correct Answer is C
Explanation
Choice A rationale
Performing the most invasive assessment first can cause distress and fear in a preschooler. It’s generally recommended to start with less invasive procedures to build trust and cooperation.
Choice B rationale
Separating a child from their caregiver during an examination can cause anxiety and fear. It’s often beneficial to have the caregiver present during the examination to provide comfort and reassurance.
Choice C rationale
Allowing a child to role-play using miniature equipment can help alleviate fears and anxieties about the examination. It gives the child a sense of control and understanding of what to expect.
Choice D rationale
While it’s important to explain procedures to a child, using medical terminology can confuse and scare them. It’s better to use simple, age-appropriate language that the child can understand.
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