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.)
The Correct Answer is "{\"xRanges\":[207.828125,247.828125],\"yRanges\":[145,185]}"
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Absence of Babinski reflex: The Babinski reflex (a fanning of the toes when the sole of the foot is stroked) is normal in infants and should be present until around 12 months of age. Its absence at 6 weeks would be atypical.
B. Absence of Moro reflex: The Moro reflex (a startle response) is typically present in newborns and may begin to disappear by 3-6 months of age. Its absence at 6 weeks would be concerning and could indicate neurological issues.
C. Closure of the posterior fontanel: The posterior fontanel typically closes by 6-8 weeks of age. This is a normal finding for a 6-week-old infant.
D. Closure of the anterior fontanel: The anterior fontanel typically closes between 12 and 18 months of age, not by 6 weeks. Therefore, closure of the anterior fontanel at 6 weeks would be unusual.
Correct Answer is C
Explanation
A. Skin condition: The fine rash noted on the chest and abdomen is not itchy, which is a common finding in infectious mononucleosis. It is not a primary concern unless it worsens or develops other characteristics, but it is not the most urgent issue to report.
B. Temperature: The client's temperature of 38.2°C (100.8°F) is slightly elevated, which is typical in infectious mononucleosis. It is within the expected range for the condition, and the prescribed acetaminophen should help manage the fever.
C. Pain level: The client reports significant pain in the left upper quadrant (rated 8 on a scale of 0 to 10) that worsens with palpation. This could indicate splenic involvement, which is a serious complication of mononucleosis, as the spleen can become enlarged and rupture.
D. Intake: The client is drinking at least 8 cups of water per day and eating about 60% of meals, which is an adequate fluid intake for the current state. Although not perfect, the intake is not a primary concern at this time compared to the pain level.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.