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?
Radial artery
Brachial artery
Apex of the heart
Carotid artery
The Correct Answer is C
A. The radial artery is commonly used for assessing the pulse in older children and adults but is less reliable in infants.
B. The brachial artery is often used to measure blood pressure in infants, but it may not be as accurate for heart rate assessment.
C. The apex of the heart (apical pulse) is the preferred site for assessing the heart rate in infants.
It is located at the point of maximal impulse (PMI).
D. The carotid artery is typically not used for routine assessment of the heart rate in infants
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. The described behaviors, such as sitting quietly and turning away, may suggest the toddler is seeking comfort and self-soothing, which can be indicative of developing autonomy rather than anxiety.
B. Resentment toward the mother is a less likely interpretation of these behaviors, especially considering the age of the toddler.
C. Developing autonomy is a common developmental stage around this age. Toddlers begin to explore their independence and may engage in self-soothing behaviors.
D. Regression is a return to an earlier developmental stage. The behaviors described are more consistent with the development of autonomy rather than regression.
Correct Answer is D
Explanation
A. Discouraging visits from friends may contribute to social isolation, which can negatively
impact the child's psychosocial well-being. Encouraging social interactions, when appropriate, is generally beneficial.
B. While play therapy may be useful in certain situations, it may not be the primary focus for a 10-year-old child. Encouraging age-appropriate activities and interactions, including school work, is important.
C. Varying the child's schedule each day might introduce unnecessary stress and disrupt the sense of routine and stability, which is essential for psychosocial well-being.
D. Encouraging the client to complete school work is aligned with Erikson's psychosocial stage of industry vs. inferiority. This stage emphasizes the importance of developing competence and skills, including academic achievements, during the school-age years. Supporting the child's educational needs is crucial for positive psychosocial development.
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