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

Answer and Explanation

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

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Correct Answer is B

Explanation

A. Breastfeeding is an option for infants with gastroesophageal reflux. It does not necessarily require a switch to formula feeding.

B. Keeping the baby in an upright position after feedings helps prevent gastroesophageal reflux by allowing gravity to assist in keeping stomach contents down.

C. Thickening formula with oatmeal is a potential intervention for infants with gastroesophageal reflux, but this is not the primary recommendation in this scenario.

D. Positioning the baby side-lying during sleep can increase the risk of aspiration and is not recommended. The baby should be placed on the back to sleep to reduce the risk of sudden infant death syndrome (SIDS).

A. Absent Rovsing's sign B. Low-grade fever C. Sudden decrease in abdominal pain D. Flaccid abdomen

Correct Answer is D

Explanation

A. Rovsing's sign is a rebound tenderness felt in the right lower quadrant when the left lower quadrant is palpated. It may be positive in acute appendicitis but is not indicative of perforation.

B. A low-grade fever is common in acute appendicitis but may not necessarily indicate perforation.

C. A sudden decrease in abdominal pain may indicate perforation, but it is not a definitive sign.

Perforation can lead to a temporary relief of pain as the irritants spread throughout the peritoneum.

D. A flaccid abdomen (soft and lacking muscular tension) can be a sign of peritonitis, which may occur due to perforation of the appendix. It suggests irritation of the peritoneum and is a more significant concern than a localized infection.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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