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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Free Nursing Study Resources

Correct Answer is ["90"]

Explanation

The correct answer is less than 90 beats per minute.

Step 1 is to understand the guidelines for administering digoxin to infants. According to the American Academy of Pediatrics, the nurse should withhold the dose if the infant’s apical heart rate is less than 90 beats per minute.

A. Low birth weight B. Appropriate for gestational age C. Large for gestational age D. Small for gestational age

Correct Answer is B

Explanation

Choice A rationale
Low birth weight is defined as a birth weight of less than 2500 grams. This newborn weighs 3200 grams, so it does not fall into this category.
Choice B rationale
A newborn is considered appropriate for gestational age if its weight falls between the 10th and 90th percentile for its gestational age. This newborn’s weight is in the 60th percentile for its gestational age of 38 weeks, so it is appropriate for gestational age.
Choice C rationale
Large for gestational age refers to a newborn whose weight is above the 90th percentile for its gestational age. This newborn’s weight is in the 60th percentile, so it does not fall into this category.
Choice D rationale
Small for gestational age refers to a newborn whose weight is below the 10th percentile for its gestational age. This newborn’s weight is in the 60th percentile, so it does not fall into this category.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer digoxin to a 6-month-old infant. Before administering the dose, the nurse measures the apical heart rate. The nurse should withhold the dose if the infant’s apical heart rate is less than what rate? .

Correct Answer is ["90"]

Explanation

A nurse is caring for a newborn who was born at 38 weeks of gestation, weighs 3,200 g, and is in the 60th percentile for weight. How should the nurse classify this neonate based on the weight and gestational age?

Correct Answer is B

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?