A nurse is collecting data from a 1-week-old infant who is scheduled for a cardiac catheterization. Which of the following locations should the nurse palpate in order to identify the infant's point of maximal impulse? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)
A
B
C
None
None
None
The Correct Answer is B
Point A: Represents the third intercostal space at the right sternal border, which corresponds anatomically to the aortic valve area. This is a key auscultation site used during cardiac assessment to listen for murmurs and abnormalities related to the aortic valve. It is not used for palpation.
Point B: Fourth intercostal space at the left midclavicular line and is the correct location for palpating the point of maximal impulse (PMI) in infants and young children. In this age group, the PMI is typically found here due to the more horizontal position of the heart in the chest.
Point C: This location is at the 2nd or 3rd intercostal space, which is too high to assess the PMI in an infant. This area is used more for evaluating pulmonic valve sounds, not the apex of the heart.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Give the infant a bottle immediately before the infant's bedtime: Feeding the infant immediately before bedtime can increase the risk of reflux as lying down soon after feeding can worsen gastroesophageal reflux. The infant should be kept upright after feeding.
B. Keep the infant at a 30-degree angle for 1 hour following each feeding: Keeping the infant upright at a 30-degree angle for about 30 to 60 minutes after feeding can help prevent the contents of the stomach from refluxing into the esophagus.
C. Limit the infant's formula feedings to every 6 hr: Infants with gastroesophageal reflux typically need more frequent feedings, not less. Limiting feedings to every 6 hours is not appropriate for a 2-month-old infant. Frequent, smaller feedings may help manage reflux.
D. Change the infant's formula to a soy-based formula: Switching to a soy-based formula is not a standard treatment for gastroesophageal reflux unless there is a specific allergy or intolerance to cow's milk protein. This should only be done if directed by the healthcare provider.
Correct Answer is C
Explanation
A. Gently cleanse the surgical site with sterile gauze: direct vigorous cleansing of the palate surgical site with gauze is generally avoided to prevent disruption of sutures. Oral rinses or specific gentle cleaning methods may be prescribed, but direct gauze wiping is usually not recommended.
B. Offer a pacifier with glucose syrup: acifiers and any sucking on objects (including straws, spoons, or toys) are typically contraindicated after cleft palate repair because the sucking motion puts stress on the suture line and can disrupt healing.
C. Apply elbow immobilizers to both arms: Elbow immobilizers prevent the infant from bending their elbows and bringing their hands to their mouth or face, which could disrupt the surgical sutures, cause trauma, or introduce infection to the delicate palate repair.
D. Place the infant in a supine position: A semi-upright position is usually preferred to reduce pressure on the surgical site and prevent aspiration, rather than placing the infant flat on their back.
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