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?

Choice A rationale
While an area of warmth can be a symptom of deep vein thrombosis (DVT), it is not the most specific or indicative symptom. DVT is a condition in which blood clots form in veins located deep inside the body, usually in the thigh or lower legs. The most common symptoms include swelling of the foot, ankle, or leg, usually on one side, cramping of the affected leg, severe leg pain, and skin on the affected area that is warmer than the skin on surrounding areas.
However, these symptoms can also be associated with other conditions, making them less specific for DVT.
Choice B rationale
Nausea is not typically a symptom of deep vein thrombosis (DVT). The most common symptoms of DVT include swelling of the foot, ankle, or leg, usually on one side, cramping of the affected leg, severe leg pain, and skin on the affected area that is warmer than the skin on surrounding areas.
Choice C rationale
A cool-to-touch extremity is not typically a symptom of deep vein thrombosis (DVT). In fact, the skin over the affected area is often warmer than the skin on surrounding areas. Therefore, a cool-to-touch extremity would not typically be expected in a client with suspected DVT.
Choice D rationale
Calf tenderness when massaged is a common clinical finding in clients with deep vein thrombosis (DVT)2. DVT often causes pain and swelling in the affected leg, and this pain can be particularly noticeable or worsen when the calf is massaged or the client is standing or walking. Therefore, calf tenderness when massaged would be a clinical finding that a nurse should anticipate in a client being admitted with a suspected DVT.

Choice A rationale
Restraining a child during a seizure is not recommended. It does not stop the seizure and can lead to injury. The child’s movements during a seizure are involuntary, so trying to stop them can cause harm.
Choice B rationale
Placing the child in a side-lying position is recommended during a seizure. This position helps to prevent aspiration, which can occur if the child vomits during the seizure.
Choice C rationale
It is a common misconception that a person having a seizure can swallow their tongue, but this is not true. Attempting to place a tongue depressor or any other object in the child’s mouth during a seizure can cause injury to the child’s teeth or jaw.
Choice D rationale
Assessing the child’s airway patency is crucial during a seizure. Seizures can cause changes in breathing patterns and can potentially lead to respiratory distress. Therefore, monitoring the child’s breathing during a seizure is important.
Choice E rationale
Removing objects from the child’s bed or surrounding area can help prevent injury during a seizure. During a seizure, the child may have uncontrolled movements, and removing nearby objects can help ensure the child’s safety.