A nurse is preparing to measure an infant's vital signs. The nurse should use which of the following sites to assess a heart rate?
Apex of the heart
Carotid artery
Brachial artery
Radial artery
The Correct Answer is C
When assessing the heart rate in an infant, the nurse should use the brachial artery. The brachial artery is located in the upper arm, and it is easily accessible in infants for measuring the heart rate by palpation. The other sites mentioned are not typically used for heart rate assessment in infants.
Option A (Apex of the heart) is not a site for directly measuring the heart rate; it is a location on the chest where the heartbeat can be heard most clearly with a stethoscope.
Option B (Carotid artery) is a site commonly used to assess the pulse in older children and adults but is generally not used for infants due to its location and risk of injury.
Option D (Radial artery) is a site commonly used to assess the pulse in older children and adults, but it can be challenging to locate and accurately measure in infants, especially during emergency situations. The brachial artery is the preferred site for infants.
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Related Questions
Correct Answer is B
Explanation
In this scenario, the infant has a heart rate of 190/min and a fever of 40°C (104°F). Fever in infants can cause an increase in heart rate, which is a normal physiological response to elevated body temperature. Fever is the body's way of responding to an infection or illness, and it triggers various physiological changes, including an increase in heart rate. This helps the body to circulate blood and deliver immune cells to fight off the infection.
The other options are not accurate or relevant to the infant's current condition:
A. "This is within the expected range for your baby." - A heart rate of 190/min is above the normal expected range for a 2-month-old infant, which is typically between 120 to 160 beats per minute. This response would not address the elevated heart rate and fever.
C. "As your baby begins to fall asleep, his heart rate will decrease." - While heart rate may decrease during sleep, it does not explain the elevated heart rate and fever observed in this situation.
D. "Your baby's heart is beating fast in an attempt to cool down his body." - While tachycardia (fast heart rate) can be associated with increased metabolic demands during fever, the main reason for the increased heart rate in this case is the fever itself, not the body's attempt to cool down. Fever is a response to infection or illness and can cause an increase in heart rate as part of the body's normal immune response.
Correct Answer is A
Explanation
For a child with von Willebrand disease experiencing a nosebleed, the nurse should instruct the parent to have the child sit with their head tilted forward slightly (not backward) to prevent blood from flowing down the throat. Applying direct pressure to the nostrils with fingers or using a clean cloth for about 10 minutes will help stop the bleeding.
Option B (applying ice at the base of the nose) is not recommended because ice can cause vasoconstriction, potentially prolonging bleeding in individuals with bleeding disorders.
Option C (placing the child in a supine position with a pillow under the back) is also not recommended, as this can lead to blood flowing down the throat, increasing the risk of aspiration.
Option D (placing the child in a sitting position with her head tilted back) should be avoided as it can lead to blood flowing into the throat and potentially being swallowed or aspirated. This position is generally discouraged for nosebleeds.
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