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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

A. Restrain the toddler for 1 hr after the procedure:

This choice involves restraining the toddler for a period of time after the lumbar puncture procedure. However, restraining a toddler for such a prolonged period is not typically necessary and may cause distress and discomfort to the child. Moreover, prolonged restraint is not recommended as it can hinder the child's mobility and may lead to emotional distress.

B. Swaddle the toddler in a warm blanket:

Swaddling a toddler in a warm blanket may provide comfort, but it is not directly relevant to the lumbar puncture procedure itself. While comfort measures are important for overall patient care, they should not replace or interfere with the specific positioning requirements for medical procedures like a lumbar puncture.

C. Ask another nurse to assist with holding the toddler in a prone position:

This choice involves having another nurse assist in holding the toddler in a prone (face-down) position during the lumbar puncture procedure. However, the prone position is not typically used for lumbar punctures in toddlers. Placing the toddler in a prone position might make the procedure more challenging and less safe for both the child and the healthcare provider.

D. Place the toddler in a side-lying knee-chest position:

Placing the toddler in a side-lying knee-chest position is the correct action for a lumbar puncture procedure in a toddler. This position maximizes the space between the vertebrae, making it easier for the healthcare provider to access the lumbar area safely and accurately. It also helps minimize the risk of injury and discomfort for the toddler during the procedure. Therefore, this choice is the most appropriate for ensuring the success and safety of the lumbar puncture procedure.

A. "At this age you should expect your child to be upset when you leave." B. "Your child needs to rest." C. will notify the provider of his behavior." D. "Your child is responding to an overstimulating environment."

Correct Answer is A

Explanation

A. "At this age you should expect your child to be upset when you leave.": This statement provides normalcy to the parents' experience and reassures them that their child's reaction is typical for his age. It acknowledges the child's developmental stage and separation anxiety, helping to alleviate parental concerns.

B. "Your child needs to rest.": While rest is important for infants, this statement does not address the child's emotional needs or the parents' concerns about leaving their child. It may also minimize the significance of the child's distress.

C. "I will notify the provider of his behavior.": Notifying the healthcare provider may be appropriate if the child's distress continues or if there are concerns about the child's well-being, but this statement does not directly address the parents' concerns or provide guidance on how to manage the situation.

D. "Your child is responding to an overstimulating environment.": This statement suggests a possible cause for the child's distress but does not provide guidance or reassurance to the parents on how to address the situation or manage their child's reaction.

View Question and Answer

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

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a toddler who is scheduled to have a lumbar puncture. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is caring for an 8-month-old child who starts to cry when his parents leave. The nurse should make which of the following statements to the parents?

Correct Answer is A

Explanation

A nurse is contributing to the plan of care for a 2-month-old infant who has just undergone cleft palate repair. The nurse should contribute which of the following interventions to the client's plan of care?

A nurse is caring for an adolescent who is having a sickle cell crisis. Which of the following nursing actions should the nurse take?

A nurse is collecting data from an infant who has developmental dysplasia of the hip (DDH). Which of the following findings should the nurse expect?

A nurse is caring for a 4-year-old child who is 2 days postoperative following the insertion of a ventriculoperitoneal shunt. Which of the following findings should the nurse identify as the priority?

While administering ear drops to a toddler, a nurse by pulls the auricle down and back. The mother asks, "Why are you pulling the ear that way?" Which of the following responses should the nurse make?

A nurse is reinforcing teaching about diagnostic tests with the parents of a child who has suspected cystic fibrosis. Which of the following diagnostic tests should the nurse include as the most definitive when diagnosing cystic fibrosis?

Primary care provider orders cefazolin (Kefrol) 30 mg/kg in two divided doses per day for a child with pneumonia. Child weighs 20 lb. If the available oral suspension is 125 mg/5ml how many mls per dose should the child receive?

A nurse is caring for a child who is experiencing an acute asthma attack. Which of the following medications should the nurse administer first?