A nurse is collecting data from an infant.
Which of the following sites is the most reliable location to check the infant’s pulse?
Carotid.
Dorsalis pedis.
Temporal.
Apical.
The Correct Answer is D
Choice A rationale
The carotid pulse is not the most reliable location to check an infant’s pulse because it can be difficult to locate and can cause discomfort to the infant.
Choice B rationale
The dorsalis pedis pulse is not the most reliable location to check an infant’s pulse because it can be difficult to locate in small infants.
Choice C rationale
The temporal pulse is not the most reliable location to check an infant’s pulse because it can be affected by external factors such as temperature and can be difficult to locate in small infants.
Choice D rationale
The apical pulse is the most reliable location to check an infant’s pulse. It is located at the apex of the heart and can be easily heard using a stethoscope. It provides the most accurate assessment of the heart rate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Edema in the palm of the hand is a sign of IV infiltration. IV infiltration occurs when IV fluids or medications leak into the surrounding tissues outside the intended vein. This can cause swelling or edema, which is a common sign of infiltration.
Choice B rationale
Absence of blanching at the insertion site is not necessarily an indication of an infiltration. Blanching (whitening of the skin) can occur due to various reasons, including pressure on the site or a reaction to the IV fluid or medication. However, it is not a definitive sign of infiltration.
Choice C rationale
Warmth around the insertion site is not a definitive sign of an infiltration. While warmth can occur due to inflammation or infection, it is not a specific sign of infiltration.
Choice D rationale
Blood in the IV tubing is not a definitive sign of an infiltration. While blood can back up into the IV tubing due to various reasons, including a blocked or kinked catheter, it is not a specific sign of infiltration.
Correct Answer is C
Explanation
Choice A rationale
Applying lotion to the newborn’s skin twice per day is not necessary during phototherapy. The main goal of phototherapy is to reduce the level of bilirubin in the newborn’s blood. Applying lotion can interfere with the effectiveness of the light therapy and can cause the newborn’s skin to overheat.
Choice B rationale
Monitoring the newborn’s blood glucose level hourly is not necessary during phototherapy unless the newborn has a specific condition that requires close monitoring of blood glucose levels. Phototherapy does not directly affect blood glucose levels.
Choice C rationale
Encouraging the newborn to breastfeed every 2 hours is an important part of the care plan for a newborn undergoing phototherapy. Frequent feeding can help to promote the excretion of bilirubin through the newborn’s stool.
Choice D rationale
Maintaining the newborn in a prone position is not necessary during phototherapy. The newborn should be placed in a variety of positions to ensure that all areas of the skin are exposed to the light.
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