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?

Radial artery

Brachial artery

Apex of the heart

Carotid artery

Answer and Explanation

The Correct Answer is C

A. The radial artery is commonly used for assessing the pulse in older children and adults but is less reliable in infants.

B. The brachial artery is often used to measure blood pressure in infants, but it may not be as accurate for heart rate assessment.

C. The apex of the heart (apical pulse) is the preferred site for assessing the heart rate in infants.

It is located at the point of maximal impulse (PMI).

D. The carotid artery is typically not used for routine assessment of the heart rate in infants

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Scoliosis is a lateral curvature of the spine. It is commonly assessed during routine physical examinations, especially in adolescents.

B. Lordosis refers to an exaggerated inward curvature of the spine, typically in the lumbar region.

C. Torticollis is a condition characterized by a tilt of the head to one side due to the shortening of muscles on one side of the neck.

D. Kyphosis is an exaggerated outward curvature of the thoracic spine, leading to a rounded upper back.

A. Body weight B. Blood pressure C. Skin integrity D. Respiratory rate E. Respiratory rate

Correct Answer is A

Explanation

A. Body weight is the most reliable indicator of fluid loss in an infant. Changes in weight can reflect changes in fluid balance more accurately than other parameters.
B. Blood pressure may be affected by severe dehydration, but it is not as sensitive or specific as changes in body weight.
C. Skin integrity can be affected by dehydration, but it is not as direct a measure of fluid loss as changes in body weight.
D. Respiratory rate can be influenced by various factors, including respiratory distress, and is not as specific to fluid loss as changes in body weight.

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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

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