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 .

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale
The nurse should reassure the patient by informing her about the hospital’s capabilities to handle such situations. The neonatal unit in the hospital is equipped to handle emergencies and care for preterm babies. This response is factual and directly addresses the patient’s concern about the baby’s well-being.
Choice B rationale
While it’s true that everyone worries about their baby when they’re in labor, this response doesn’t directly address the patient’s concern about the baby’s health and well-being. It’s more of a general statement and doesn’t provide the reassurance the patient is seeking.
Choice C rationale
This response acknowledges the patient’s feelings, which is an important aspect of patient care. However, it doesn’t provide any information or reassurance about the baby’s health. The patient is specifically asking about the baby’s well-being, so the response should focus on that.
Choice D rationale
This response could be misleading. While it’s true that the chances of survival for preterm babies improve with each passing week, it’s not guaranteed that a baby born at 32 weeks will be fine. It’s important to provide accurate information and not give false reassurances.

A. Client has had two prior pregnancies B. Client is currently pregnant with twins C. Client is at risk for miscarriage D. Client has had one full-term birth E. Client has one living child

Correct Answer is ["A","D","E"]

Explanation

Choice A rationale
The G in GTPAL stands for gravida, which is the number of times an individual has conceived, including any current pregnancy. In this case, G3 means the client has had three pregnancies, which includes two prior pregnancies and the current one.
Choice B rationale
The client’s record does not indicate that she is currently pregnant with twins, making this choice incorrect.
Choice C rationale
The A in GTPAL stands for the number of abortions, which refers to all times the individual has lost a pregnancy before 20 weeks. In this case, A1 means the client has had one abortion, indicating a risk for miscarriage.
Choice D rationale
The T in GTPAL stands for term births, which refers to the number of times an individual has carried a pregnancy to at least 37 weeks of gestation and delivered. In this case, T1 means the client has had one full-term birth.
Choice E rationale
The L in GTPAL stands for living children. In this case, L1 means the client has one living child.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is attending to a patient who is in preterm labor at 32 weeks of gestation. The patient asks the nurse, “Will my baby be okay?” What should the nurse respond?

Correct Answer is A

Explanation

A nurse in a prenatal clinic is caring for a client in the first trimester of pregnancy. The client’s health record includes this data: G3 T1 P0 A1 L1. How should the nurse interpret this information? (Select all that apply.)

Correct Answer is ["A","D","E"]

Explanation

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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?