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 A
Explanation
A. Correct. Having the child stand against a wall and marking their height with a pen provides an accurate measurement of height in children who are able to stand.
B. Incorrect. Instructing the child to lie down on the examination table is not the appropriate method for measuring height in a standing child.
C. Incorrect. Using a tape measure to measure the distance from head to toe is not as accurate as having the child stand against a wall for measurement.
D. Incorrect. Estimating height based on age and weight is not a reliable method for obtaining an accurate measurement.
Correct Answer is C
Explanation
A. Incorrect. Weighing the child while wearing clothes may lead to an inaccurate measurement. It's best to weigh the child without excess clothing.
B. Incorrect. Using a bathroom scale designed for adults is not suitable for accurately measuring a toddler's weight.
C. Correct. Using a flat, stable surface for weighing ensures accuracy in measurement.
D. Incorrect. Allowing the child to hold onto a toy during the measurement may introduce additional variables that could affect the accuracy of the weight measurement.
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