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 A
Explanation
A. "It is expected for children who are hospitalized to regress. The toileting skills will return when your child is feeling better." Hospitalization can be stressful and disruptive for children, often causing temporary regression Reassuring parents that this behavior is common and usually resolves as the child recovers helps reduce parental anxiety and supports understanding.
B. "Why does it bother you that your child has wet the bed?" This response may come across as confrontational or judgmental, potentially increasing the parent's distress rather than providing comfort or support during a vulnerable moment.
C. "I know this can really be embarrassing. I have kids myself, so I understand, and it doesn't bother me." While this statement shows empathy, it may unintentionally shift focus to the nurse’s experience rather than validating the parent’s feelings. A more supportive response addresses the child’s needs and parental concerns directly.
D. "Your child did not seem upset, so I wouldn't worry about it if I were you." Dismissing the parent's feelings about the situation may cause them to feel unheard or invalidated. Acknowledging the parent's emotions while providing reassurance is a more supportive approach.
Correct Answer is C
Explanation
A. Inability to pick up an object with her fingers: At 3 months, infants typically do not have the fine motor skills to grasp objects deliberately with fingers. This milestone usually develops around 4 to 6 months, so this finding is not concerning at this age.
B. Inability to bring an object to her mouth: This milestone generally emerges around 4 to 6 months as infants gain better hand-eye coordination and voluntary control. Lack of this skill at 3 months is expected and not necessarily a delay.
C. Inability to raise head when in prone position: By 3 months, infants usually can lift and briefly hold their head up while lying on their stomach, demonstrating neck muscle strength. If the infant cannot do this, it may indicate a developmental concern.
D. Inability to sit without support: Sitting independently without support is a major gross motor milestone that typically develops much later in infancy, usually between 6 to 8 months of age. A 3-month-old infant is not expected to be able to sit without support, so this is a normal finding and not a concern.
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