A nurse is preparing to measure an infant’s vital signs.
Which of the following sites should the nurse use to assess the heart rate?
Carotid artery
Brachial artery
Apex of the heart
Radial artery .
The Correct Answer is C
Choice C rationale
The apex of the heart is the most appropriate site to assess an infant’s heart rate. In infants, the apical pulse provides the most accurate assessment of heart rate. The apical pulse is located at the fifth intercostal space at the midclavicular line.
Choice A rationale
The carotid artery is not typically used to assess an infant’s heart rate. This site is more commonly used in adults and older children.
Choice B rationale
The brachial artery can be used to assess an infant’s heart rate, but it is typically used for blood pressure measurements rather than heart rate assessments.
Choice D rationale
The radial artery is not typically used to assess an infant’s heart rate. This site is more commonly used in adults and older children.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Iron supplements should not be administered in one large dose every day. High doses can cause side effects such as nausea, vomiting, diarrhea, constipation, and dark stools.
Choice B rationale
Monitoring blood count routinely for several weeks is necessary when a child is taking iron supplements for iron deficiency anemia. This helps to ensure that the supplement is effective and that iron levels are being restored to a healthy range.
Choice C rationale
Iron supplements are not necessarily more effective if administered with meals. In fact, some studies suggest that taking iron supplements with food might decrease the amount of iron absorbed.
Choice D rationale
Restricting fiber from a child’s diet will not necessarily help with the absorption of iron. In fact, a balanced diet, including fiber, is important for overall health.
Correct Answer is ["A","B","C","D"]
Explanation
Choice A rationale
Flushing and sweating can be an indication of magnesium sulfate toxicity. Magnesium sulfate is a medication used to prevent seizures in women with severe preeclampsia. However, if the levels of magnesium become too high, it can lead to toxicity15.
Choice B rationale
A decreased level of consciousness can be an indication of magnesium sulfate toxicity. High levels of magnesium can affect the central nervous system, leading to drowsiness, lethargy, and decreased responsiveness15.
Choice C rationale
Urinary output less than 30 mL/hr can be an indication of magnesium sulfate toxicity. Magnesium sulfate can affect kidney function, leading to decreased urine output15.
Choice D rationale
Respirations fewer than 12/min can be an indication of magnesium sulfate toxicity. High levels of magnesium can depress the respiratory system, leading to slow or shallow breathing15.
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