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
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
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Discouraging visits from friends may contribute to social isolation, which can negatively
impact the child's psychosocial well-being. Encouraging social interactions, when appropriate, is generally beneficial.
B. While play therapy may be useful in certain situations, it may not be the primary focus for a 10-year-old child. Encouraging age-appropriate activities and interactions, including school work, is important.
C. Varying the child's schedule each day might introduce unnecessary stress and disrupt the sense of routine and stability, which is essential for psychosocial well-being.
D. Encouraging the client to complete school work is aligned with Erikson's psychosocial stage of industry vs. inferiority. This stage emphasizes the importance of developing competence and skills, including academic achievements, during the school-age years. Supporting the child's educational needs is crucial for positive psychosocial development.
Correct Answer is C
Explanation
A. Blaming the family may increase the child's sense of guilt or shame. It's important to focus on supporting the child rather than blaming the family outright.
B. Promising not to tell anyone may compromise the child's safety. Reporting abuse is essential to protect the child.
C. Affirming that it is not the child's fault helps to alleviate potential feelings of guilt or responsibility. This statement supports the child emotionally.
D. Discussing the incident with the family directly may not be safe for the child. Reporting suspicions of abuse to the appropriate authorities is necessary.
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