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. Pinto beans: Pinto beans are a good source of protein, but they are not considered a complete protein. They lack some of the essential amino acids, although they can be paired with other foods (like rice) to form a complete protein.
B. Peanut butter: Peanut butter is a good source of protein, but like pinto beans, it is not a complete protein. It lacks some essential amino acids, and while it can be part of a balanced diet, it does not provide all the necessary amino acids on its own.
C. Eggs: Eggs are an excellent source of complete protein because they contain all nine essential amino acids that the body cannot produce on its own. They are considered one of the best sources of high-quality, complete protein.
D. Broccoli: While broccoli contains some protein, it is not a complete protein. It provides some essential amino acids, but not all nine, so it does not qualify as a complete protein source on its own.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"}}
Explanation
Rationale:
- Insert a peripheral IV catheter: A peripheral IV catheter is essential for administering fluids and medications, which is critical for this adolescent, especially with the concern for bacterial meningitis.
- Place the adolescent on a cooling blanket: The adolescent has a high fever (39°C), which needs to be managed promptly to prevent further complications. A cooling blanket helps reduce the fever and manage the patient’s temperature.
- Administer IV acyclovir: Acyclovir is an antiviral medication typically used to treat viral infections such as herpes simplex virus or varicella-zoster virus, not bacterial meningitis. Given the CSF findings and suspected bacterial meningitis, acyclovir is not appropriate. Antibiotics like cefotaxime are indicated instead.
- Place on seizure precautions: Given the adolescent's symptoms (e.g., headache, photophobia, lethargy), the risk of seizures is elevated, especially if meningitis is suspected. Seizure precautions are important to prevent injury during a potential seizure.
- Keep adolescent flat in bed for 24 hr post lumbar puncture: After a lumbar puncture, keeping the adolescent flat in bed for 24 hours helps prevent post-lumbar puncture headaches and minimizes the risk of cerebrospinal fluid leaks or complications.
- Administer IV cefotaxime: IV cefotaxime is an appropriate antibiotic for treating bacterial meningitis. Given the abnormal CSF results (low glucose, high protein, elevated WBC), the adolescent is at high risk for bacterial meningitis, and IV cefotaxime is expected to be part of the treatment plan.
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