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?
Carotid artery
Radial artery
Apex of the heart
Brachial artery
The Correct Answer is C
A. Carotid artery: The carotid artery is not typically used to assess heart rate in infants due to its location and difficulty in palpation.
B. Radial artery: The radial artery is not typically used to assess heart rate in infants, especially in non-cooperative or newborn infants.
C. Apex of the heart: Assessing the heart rate by auscultating the apex of the heart with a stethoscope is the most accurate method for infants.
D. Brachial artery: The brachial artery is not typically used to assess heart rate in infants. It is commonly used to measure blood pressure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. A 7-year-old child who has diabetes insipidus and a urine specific gravity of 1.016: While diabetes insipidus requires monitoring and management, a urine specific gravity of 1.016 alone does not indicate acute distress or an emergency situation. The child may need adjustments in fluid intake or medication, but this can typically be addressed in a less urgent manner.
B. A 10-year-old child who has sickle cell anemia who reports severe chest pain: Severe chest pain in a child with sickle cell anemia could indicate a vaso-occlusive crisis affecting the chest, which is potentially life-threatening. Prompt assessment and intervention are necessary to
manage the pain and prevent complications, including acute chest syndrome or respiratory compromise.
C. A 1-year-old toddler who has roseola and a temperature of 39°C (102.2°F): Roseola is typically a benign viral illness characterized by fever and a rash. While a fever in a young child
requires monitoring and symptomatic management, it is not usually considered an emergency unless accompanied by other concerning symptoms such as dehydration or respiratory distress.
D. A 4-year-old child who has asthma and a PCO2 of 37 mm: While asthma exacerbations can be serious, a PCO2 level of 37 mm indicates normal carbon dioxide levels, which do not suggest acute respiratory distress or impending respiratory failure. However, if the child is experiencing severe respiratory distress, cyanosis, or altered mental status, immediate assessment and
intervention would be warranted.
Correct Answer is A
Explanation
A. "I will give him a pacifier during feeding time.": Giving a pacifier during feeding time may interfere with the infant's ability to coordinate sucking, swallowing, and breathing, especially if
they are receiving nutrition through a nasogastric tube. This response indicates a need for further teaching because pacifiers during feeding time could potentially disrupt the infant's feeding
pattern and may not be appropriate in this situation.
B. "We need to make sure he doesn't lose the desire to eat by mouth.": This response
demonstrates an understanding of the importance of maintaining the infant's oral feeding skills and indicates appropriate knowledge about promoting oral feeding while using a nasogastric
tube.
C. "We need to keep feeding time very quiet.": Keeping feeding time quiet can help reduce distractions and promote a calm environment, which may enhance feeding tolerance for the infant. This response reflects an understanding of strategies to facilitate feeding.
D. "Sucking produces saliva, which aids in digestion.": This response demonstrates knowledge about the benefits of sucking and saliva production during feeding, indicating an understanding of the infant's physiological needs during feeding.
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