A nurse is preparing to measure an infant's respiratory rate. Which technique should the nurse use?
Place the hand on the abdomen to count respirations.
Count respirations while the infant is sleeping.
Visually observe chest movement for 30 seconds.
Use a stethoscope to listen for breath sounds.
The Correct Answer is A
A. Correct. Placing the hand on the infant's abdomen allows the nurse to feel the rise and fall with each breath, providing an accurate count of respiratory rate.
B. Incorrect. Counting respirations while the infant is sleeping may be challenging and may not provide an accurate assessment.
C. Incorrect. While visually observing chest movement can be helpful, this method may not be as accurate as feeling the actual movement with the hand.
D. Incorrect. Using a stethoscope to listen for breath sounds is not the recommended method for measuring respiratory rate in infants.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Incorrect. A cuff that covers only 50% of the upper arm circumference may be too small and lead to falsely elevated blood pressure readings.
B. Correct. Selecting a cuff that covers approximately 75% of the upper arm circumference is recommended for accurate blood pressure measurement in children. This ensures proper fit and accurate readings.
C. Incorrect. Using a cuff that covers 100% of the upper arm circumference may be too large, resulting in falsely low blood pressure readings.
D. Incorrect. A cuff that covers 125% of the upper arm circumference is overly large and not appropriate for accurate blood pressure measurement.
Correct Answer is B
Explanation
A. Incorrect. Pulling the child's earlobe down and back is a technique used for straightening the ear canal in older children and adults, not for using a tympanic thermometer.
B. Correct. When using a tympanic thermometer, it's important to gently insert the probe into the ear canal and ensure a proper seal. This helps to obtain an accurate temperature reading.
C. Incorrect. Holding the thermometer in place for 1-2 minutes is not the correct technique for tympanic temperature measurement. It may lead to an inaccurate reading.
D. Incorrect. Using an oral thermometer for a 2-year-old child is not the recommended method, as it may not provide an accurate temperature reading.
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