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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Applying suction for 20 seconds:
Suctioning for 20 seconds is within the recommended duration for endotracheal suctioning in children. It allows adequate time for removing secretions without causing excessive trauma to the airway.
B. Introducing the catheter without suction:
This action is incorrect. When performing endotracheal suctioning, the catheter should be introduced into the endotracheal tube while applying suction. Introducing the catheter without suction may not effectively remove secretions and can lead to ineffective suctioning.
C. Rotating the catheter between the thumb and forefinger while suctioning:
Rotating the catheter between the thumb and forefinger while suctioning helps to prevent the catheter from sticking to the airway walls and facilitates the removal of secretions. This action is appropriate and helps ensure effective suctioning.
D. Allowing the child to rest for 30 to 60 seconds between suctioning passes:
Allowing the child to rest between suctioning passes helps minimize hypoxia and discomfort during the procedure. This action is appropriate and ensures that the child has adequate time to recover before the next suctioning pass.
Correct Answer is C
Explanation
A. "I will restrict the amount of salt in my child's meals."
Restricting salt intake is not typically recommended for children with cystic fibrosis (CF). In fact, individuals with CF often have increased salt requirements due to excessive salt loss through sweat. Restricting salt intake could potentially lead to electrolyte imbalances. Therefore, this statement does not demonstrate an understanding of the dietary management necessary for CF.
B. "I will put my child in daycare to ensure that she socializes with other children."
While socialization is important for a child's development, placing a child with CF in daycare may increase their risk of exposure to respiratory infections, which can be particularly dangerous for individuals with CF due to their compromised respiratory function. Therefore, this statement does not demonstrate an understanding of the infection control measures necessary for managing CF.
C. "I will make sure my child washes her hands before eating.”
This statement demonstrates an understanding of infection control measures, which are crucial for individuals with CF to reduce the risk of respiratory infections. Washing hands before eating helps prevent the transmission of bacteria and viruses that can cause respiratory infections. Therefore, this statement indicates an understanding of an important aspect of managing CF.
D. “I will provide low-fat meals for my child."
Providing low-fat meals is not typically recommended for children with CF. CF often leads to malabsorption of fats, so a diet high in calories and fat is typically recommended to ensure adequate nutrition and weight gain. Therefore, this statement does not demonstrate an understanding of the dietary recommendations necessary for managing CF.
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