A nurse is collecting data from an infant. Which of the following sites is the most reliable location to check the infant's pulse?

Apical

Dorsalis pedis

Temporal

Carotid

Answer and Explanation

The Correct Answer is A

A. Apical:

The apical pulse is the most reliable location to assess the pulse in infants. It is located at the apex of the heart, which is typically found at the fifth intercostal space at the midclavicular line. Assessing the apical pulse allows for a direct measure of the heart rate and rhythm, which is especially important in infants to evaluate cardiac function accurately. The apical pulse is commonly assessed using a stethoscope placed at the point of maximum impulse (PMI) on the chest.

B. Dorsalis pedis:

The dorsalis pedis pulse is located on the top of the foot, typically in the region between the first and second metatarsal bones. While the dorsalis pedis pulse can be palpated in older children and adults, it may be difficult to palpate accurately in infants, especially those with smaller or more delicate feet. Therefore, it is not the preferred site for pulse assessment in infants.

C. Temporal:

The temporal pulse is located on the side of the head, just above the ear. While the temporal pulse can be palpated in some individuals, it is not typically used to assess the pulse in infants. Palpating the temporal pulse in infants may be more challenging and less reliable compared to other pulse sites, especially given the smaller size of the temporal artery in infants.

D. Carotid:

The carotid pulse is located in the neck, alongside the trachea, and can be palpated by gently pressing the fingers against the carotid artery. While the carotid pulse is easily palpable in adults and older children, it is not typically the preferred site for pulse assessment in infants. Palpating the carotid pulse in infants carries a risk of injury to the delicate structures in the neck and may not provide an accurate representation of the pulse rate.

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Correct Answer is D

Explanation

A. Instruct the client to cough. Coughing is generally encouraged after chest physiotherapy to help expel loosened secretions, but it is not the first action. The bronchodilator should be administered first to maximize the effectiveness of the chest physiotherapy.

B. Perform vibration while the client exhales slowly through the nose. Vibration is a component of chest physiotherapy used to help loosen secretions during exhalation, but it is performed after the bronchodilator is administered and once the client is positioned properly.

C. Percuss the upper posterior chest.Percussion helps to mobilize secretions but is typically done after the bronchodilator has been administered to allow for more effective airway clearance.

D. Administer albuterol by nebulizer.Administering albuterol first dilates the airways, making it easier to mobilize and clear secretions during percussion, vibration, and postural drainage.

A. Decreased stridor B. Increased restlessness C. Decreased heart rate D. Decreased temperature

Correct Answer is B

Explanation

A. Decreased stridor: Stridor is a high-pitched, noisy breathing sound caused by turbulent airflow through a narrowed or partially obstructed airway. In laryngotracheobronchitis, stridor is often present and may worsen with increasing airway obstruction. Therefore, decreased stridor would not be a typical finding associated with airway obstruction in this condition.

B. Increased restlessness: Increased restlessness can be a sign of worsening respiratory distress and impending airway obstruction. As the child struggles to breathe, they may become increasingly agitated and restless, indicating the need for prompt intervention to ensure adequate oxygenation.

C. Decreased heart rate: Decreased heart rate (bradycardia) is not typically associated with airway obstruction in laryngotracheobronchitis. In fact, the heart rate may increase as a compensatory response to hypoxia and respiratory distress.

D. Decreased temperature: Changes in temperature are not typically associated with airway obstruction in laryngotracheobronchitis. The focus of monitoring in this condition is primarily on respiratory distress and signs of worsening airway obstruction.

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A nurse is collecting data from an infant. Which of the following sites is the most reliable location to check the infant's pulse?

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Correct Answer is D

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Correct Answer is B

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