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 C
Explanation
A. Height in girls increases rapidly after menarche and usually ceases immediately after
menarchE. Height increases during adolescence are not directly related to menarche. Growth in girls typically continues for several years after menarche, although at a slower rate compared to the pre-pubertal growth spurt.
B. Boys' growth spurts usually begin between the ages of 8 and 14 years and end between the ages of 13½ and 17½ years: While boys do experience a growth spurt during adolescence, the timing and duration of growth spurts can vary widely among individuals. Growth typically
continues beyond the age of 14, with some boys reaching their full adult height in their late teens or early twenties.
C. Peak height velocity (PHV) occurs at approximately 12 years of age in girls or about 6 to 12 months after menarchE. Peak height velocity refers to the period of most rapid growth during adolescence. In girls, PHV typically occurs around the age of 12, with growth continuing for some time after menarche.
D. Boys reach PHV and peak weight velocity (PWV) at about 16 years of agE. Boys generally experience PHV and PWV later than girls, typically occurring around the age of 14 to 16. These milestones mark the period of most rapid growth in boys, with height and weight increasing significantly during this time.
Correct Answer is B
Explanation
A. Has a fear of strangers: Fear of strangers typically emerges around 6 to 9 months of age as part of normal social development. While it indicates cognitive and emotional growth, it does not necessarily warrant further evaluation unless it is excessive or accompanied by other concerning behaviors.
B. Uses a unidextrous grasp: By 7 months, infants typically develop a more refined pincer grasp, where they can pick up small objects using the thumb and forefinger (bidextrous grasp). A unidextrous grasp (using only one hand) may suggest a delay in fine motor development and could warrant further evaluation by a healthcare provider.
C. Babbles one-syllable sounds: Babbling is a typical milestone in language development for
infants around 6 to 9 months of age. One-syllable babbling is expected at this stage and does not necessarily indicate a need for further evaluation.
D. Shows preferences towards foods: Developing food preferences is part of normal feeding behavior for infants. While it is important to ensure a balanced diet, showing preferences towards certain foods is not typically a cause for concern at this age.
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