A nurse is preparing to measure an infant's vital signs. Which sites should the nurse use to assess a heart rate?
Apex of the heart
Radial artery
Carotid artery
Brachial artery
The Correct Answer is A
A. Apex of the heart: The apical pulse is the most accurate site for measuring heart rate in infants, especially those under 2 years old. It allows the nurse to auscultate directly over the heart with a stethoscope for a full minute, capturing the true rate and rhythm, including any irregularities.
B. Radial artery: The radial pulse is not a reliable site in infants due to their small and less-developed peripheral arteries. It can be difficult to palpate and may give an inaccurate heart rate, especially if the infant is active or crying.
C. Carotid artery: The carotid artery is typically avoided in infants for routine assessment due to the risk of applying too much pressure, which can impair cerebral blood flow. It's primarily used in emergencies to check for circulation.
D. Brachial artery: The brachial artery is used for palpation during CPR or in the absence of a stethoscope, but it is not as accurate as the apical site for assessing heart rate. It's better for checking circulation than heart rhythm or rate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["5.3"]
Explanation
Convert the child's weight from pounds (lb) to kilograms (kg).
Weight in kg = 28 lb / 2.2 lb/kg
= 12.727 kg
Calculate the total desired dose in milligrams (mg).
Desired dose (mg) = Desired dose (mg/kg/dose) × Weight (kg)
= 10 mg/kg/dose × 12.727 kg
= 127.27 mg
Available concentration of the acetaminophen oral solution
= 120 mg / 5 mL.
Calculate the volume in milliliters (mL) to administer.
Volume (mL) = Desired dose (mg) / (Available concentration (mg) / Available volume (mL))
= 127.27 mg / (120 mg / 5 mL)
= 127.27 mg × (5 mL / 120 mg)
= (127.27 × 5) / 120 mL
= 636.35 / 120 mL
= 5.302 mL
Round the answer to the nearest tenth.
= 5.3 mL.
Correct Answer is B
Explanation
A. OUCHER scale: This scale uses photographs of children’s faces to help children aged 3 years and older self-report pain. It is not suitable for infants who cannot verbally communicate or understand the images.
B. FLACC scale: The FLACC (Face, Legs, Activity, Cry, Consolability) scale is an observational tool designed for infants and young children who cannot self-report pain. It assesses pain based on behavioral cues and physiological indicators, making it appropriate for a 2-month-old.
C. FACES scale: This scale involves children pointing to a series of faces to indicate their pain level, which requires cognitive and verbal skills typically seen in children aged 3 years and above, not infants.
D. PANAD scale: The Pain Assessment in Advanced Dementia (PAINAD) scale is designed to assess pain in adults with advanced dementia who cannot communicate verbally. It is not applicable to infants.
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