A nurse is preparing to measure an infant's vital signs. The nurse should use which of the following sites to assess a heart rate?

Apex of the heart

Carotid artery

Brachial artery

Radial artery

Answer and Explanation

The Correct Answer is A

A. Apex of the heart: The apex of the heart is the preferred site for measuring an infant's heart rate. It is located at the 4th or 5th intercostal space, just medial to the midclavicular line, allowing for accurate auscultation of the heartbeat.

B. Carotid artery: While the carotid artery can be used to assess heart rate in older children and adults, it is not ideal for infants due to the risk of compromising circulation to the brain if pressure is applied too forcefully.

C. Brachial artery: The brachial artery is often used to assess pulse in infants, especially in cases of CPR, but it is not the preferred site for routine heart rate measurement. It may be used when assessing circulation or checking for pulses, but auscultation at the apex is more accurate for heart rate.

D. Radial artery: The radial artery can be difficult to palpate in infants due to their small size and is generally not used for heart rate assessment in this age group. The apex is a more reliable location.

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Free Nursing Study Resources

Correct Answer is ["260"]

Explanation

To calculate the total fluid intake, we need to convert all the measurements to milliliters (mL) and then add them up:

1 cup = 240 mL

1 oz = 30 mL

Given fluid intake:

Juice: ½ cup = 0.5 * 240 mL = 120 mL

Gelatin: 3 oz = 3 * 30 mL = 90 mL

Ice pop: 1 oz = 1 * 30 mL = 30 mL

Ginger ale: 20 mL

Total fluid intake = 120 mL + 90 mL + 30 mL + 20 mL = 260 mL

So, the nurse should record 260 mL as the child's fluid intake.

A. Respiratory rate 20/min B. Abdominal pain rated 4 on a scale of 0 to 10 C. Heart rate 72/min D. Blood pressure 92/50 mm Hg

Correct Answer is D

Explanation

The nurse's priority assessment finding in an adolescent who experienced blunt trauma to the abdomen is low blood pressure (hypotension). Hypotension could indicate significant internal bleeding or hemorrhage, which is a life-threatening condition and requires immediate attention. The decreased blood pressure may be a sign of shock, and prompt intervention is needed to stabilize the client's condition and prevent further deterioration.

While all the other findings (respiratory rate, abdominal pain, and heart rate) are important and should be assessed and monitored, blood pressure is the most critical in this situation due to its potential association with severe internal injuries and the risk of hypovolemic shock.

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A nurse is preparing to measure an infant's vital signs. The nurse should use which of the following sites to assess a heart rate?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a child who is on a clear liquid diet. At lunch, the child consumed ½ cup of juice, and 3 oz gelatin. 1 oz of an ice pop, and 20 mL ginger ale. How many mL should the nurse record as the child's fluid intake?

Correct Answer is ["260"]

Explanation

A nurse is assessing an adolescent who experienced blunt trauma to the abdomen. Which of the following findings is the nurse's priority?

Correct Answer is D

Explanation

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