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?

Choice A rationale:

Nasal flaring is a sign of respiratory distress. The absence of nasal flaring would indicate improvement, but the presence of nasal flaring indicates ongoing respiratory distress.

Choice B rationale:

Retractions are also a sign of respiratory distress. The reduction or absence of retractions would indicate improvement, but their presence indicates ongoing respiratory distress.

Choice C rationale:

Oxygen saturation is a key indicator of respiratory function. An improvement in oxygen saturation levels (from 89% on room air to higher levels) indicates that the treatment plan is effective in improving the child’s oxygenation.

Choice D rationale:

Breath sounds in bilateral bases are important to assess for improvement in lung function. The presence of clear breath sounds or reduced wheezing indicates improvement in the child’s respiratory status.

Choice E rationale:

Respiratory rate is an important vital sign to monitor in respiratory conditions. A decrease in respiratory rate (from 42 breaths/min to a lower rate) indicates that the treatment plan is effective in reducing the child’s respiratory distress.

Choice F rationale:

Heart rate can be influenced by various factors, including fever, anxiety, and respiratory distress. While a decrease in heart rate may indicate improvement, it is not as specific an indicator of respiratory function as oxygen saturation and respiratory rate.

The correct answer is Choice A.

Choice A rationale

The FLACC scale (Face, Legs, Activity, Cry, Consolability) is suitable for assessing pain in infants and young children who cannot verbally communicate their pain. It evaluates five criteria to determine the level of pain.

Choice B rationale

The FACES scale is more appropriate for children aged 3 years and older who can point to the face that best represents their pain level.

Choice C rationale

The OUCHER scale is also designed for older children who can understand and use the photographic or numerical scale to indicate their pain.

Choice D rationale

The PANAD scale is used for assessing pain in patients with advanced dementia and is not suitable for infants.