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 A
A. Apex of the heart: The apex of the heart is the preferred site for measuring an infant's heart rate. It is located at the 4th or 5th intercostal space, just medial to the midclavicular line, allowing for accurate auscultation of the heartbeat.
B. Carotid artery: While the carotid artery can be used to assess heart rate in older children and adults, it is not ideal for infants due to the risk of compromising circulation to the brain if pressure is applied too forcefully.
C. Brachial artery: The brachial artery is often used to assess pulse in infants, especially in cases of CPR, but it is not the preferred site for routine heart rate measurement. It may be used when assessing circulation or checking for pulses, but auscultation at the apex is more accurate for heart rate.
D. Radial artery: The radial artery can be difficult to palpate in infants due to their small size and is generally not used for heart rate assessment in this age group. The apex is a more reliable location.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
For a 6-month-old infant who has undergone the repair of an intussusception, the nurse should select an oral electrolyte solution. This solution is specifically designed to replace lost fluids and electrolytes due to vomiting or diarrhea, which is crucial in preventing dehydration in infants.
Options A, B, and C are not suitable choices for an infant in this situation:
A. Half-strength orange juice: Citrus juices, including orange juice, are not recommended for infants under 12 months old. They are acidic and may cause stomach upset or diarrhea.
B. Sterile water: Sterile water does not contain the necessary electrolytes, and offering plain water to an infant after surgery or during an illness can lead to electrolyte imbalances and further dehydration.
C. Half-strength infant formula: Diluting infant formula can lead to inadequate nutrition for the infant. The baby requires appropriate nutrition to support recovery after surgery, and diluting formula can be harmful.
D. An oral electrolyte solution is the best choice as it helps maintain proper hydration and electrolyte balance in the infant's body during the recovery period. If the infant tolerates the oral electrolyte solution well and is not at risk for aspiration, the healthcare provider may gradually advance the diet to include other clear liquids and then slowly reintroduce regular infant formula or breast milk as appropriate. The healthcare provider's instructions should be followed carefully to support the infant's recovery and ensure adequate nutrition.
Correct Answer is D
Explanation
Cystic fibrosis (CF) is a genetic disorder that affects the production and function of certain glands, particularly those that produce mucus and sweat. One of the key aspects of CF management is addressing the pancreatic insufficiency that occurs in many individuals with CF. Due to the impairment of the pancreas, children with CF may have difficulty digesting food properly, especially fats. This can lead to malabsorption of nutrients, poor weight gain, and other nutritional deficiencies.
Pancreatic enzyme replacement therapy is a crucial part of CF management. Pancreatic enzymes are prescribed to help the child digest and absorb essential nutrients, especially fats. The enzymes are typically given with each meal and snack to aid in the breakdown and absorption of nutrients.
The other options are not correct:
A. "We will restrict the amount of salt in our child's food."
Sodium restriction is generally not a focus in CF management unless there are specific indications for it. CF patients may have increased salt losses in sweat, but dietary sodium restriction is not a primary aspect of their care.
B. "I will limit my child's fluid intake."
Fluid intake is important for children with CF to maintain hydration and prevent dehydration. There is no specific need to limit fluid intake unless there are individualized medical reasons for doing so.
C. "I will prepare low-fat meals with limited protein for my child."
Children with CF often require a high-calorie, high-protein diet to maintain adequate nutrition and growth. Restricting fat and protein intake is not typically recommended, as these nutrients are essential for a child's development and well-being. Instead, pancreatic enzymes are used to aid in the digestion and absorption of fats and other nutrients.
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