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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Correct Answer is B

Explanation

Correct answer: B

A. Increased pain: Increased pain is a common and expected finding after a tonsillectomy. The surgical removal of tonsils creates wounds in the throat, which can cause discomfort and pain during the healing process. However, increased pain alone is not a specific manifestation of hemorrhage. Hemorrhage would be indicated by other signs, such as drooling, frequent swallowing, or vomiting blood.

B. Frequent swallowing: This can indicate that the child is swallowing blood, which is a common sign of bleeding at the surgical site. Children might not always show obvious signs of bleeding in the mouth, so frequent swallowing can be a subtle but critical indicator of hemorrhage.

C. Poor fluid intake: Poor fluid intake is a common concern after a tonsillectomy due to postoperative pain and discomfort in the throat. The child may be reluctant to drink or eat initially because of their sore throat. However, poor fluid intake alone is not an indicative sign of hemorrhage. Hemorrhage would present with other symptoms, such as drooling, frequent swallowing, or vomiting blood.

D. Drooling:While drooling can occur due to discomfort, pain, or difficulty swallowing, it is not as specific or immediate a sign of hemorrhage as frequent swallowing.

Correct Answer is ["5.3."]

Explanation

To calculate the dose of acetaminophen for a child, the nurse needs to convert the child's weight from pounds to kilograms and then multiply it by the prescribed dose per kilogram. The formula is:

Weight in kg = Weight in lb / 2.2
Dose in mg = Weight in kg x Dose per kg
Dose in mL = Dose in mg / Concentration in mg/mL

Using the given information, the nurse can plug in the values and solve for the dose in mL:

Weight in kg = 28 / 2.2 = 12.73
Dose in mg = 12.73 x 10 = 127.3
Dose in mL = 127.3 / 120 x 5 = 5.3

Therefore, the nurse should administer 5.3 mL of acetaminophen to the child.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a child who is postoperative following a tonsillectomy. Which of the following findings is a manifestation of hemorrhage?

Correct Answer is B

Explanation

A nurse is preparing to administer acetaminophen 10 mg/kg/dose to a child who weighs 28 lb. The amount available is acetaminophen 120 mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["5.3."]

Explanation

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