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?
Carotid artery
Radial artery
Apex of the heart
Brachial artery
The Correct Answer is C
A. Carotid artery: The carotid artery is not typically used to assess heart rate in infants due to its location and difficulty in palpation.
B. Radial artery: The radial artery is not typically used to assess heart rate in infants, especially in non-cooperative or newborn infants.
C. Apex of the heart: Assessing the heart rate by auscultating the apex of the heart with a stethoscope is the most accurate method for infants.
D. Brachial artery: The brachial artery is not typically used to assess heart rate in infants. It is commonly used to measure blood pressure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Obtain a detailed history.
Obtaining a detailed history is essential to understand the circumstances surrounding the bruises, including how they occurred, where they are located, and whether there is a plausible
explanation for them. This information helps determine whether the bruises are due to accidental injury or potential abuse.
B. Report the suspected abuse to the authorities.
While reporting suspected abuse may ultimately be necessary if there are concerns about the origin of the bruises, obtaining a detailed history is the initial step to gather information and assess the situation before making a report.
C. Ask a psychiatrist to talk with the parents.
Involving a psychiatrist may be appropriate in cases where there are concerns about the child's mental health or the family dynamics, but it may not address the immediate concern of the bruises without first obtaining a detailed history.
D. Separate the child from the parents.
Separating the child from the parents should not be the first action taken without sufficient evidence or reason to believe that the child is in imminent danger. Gathering information through a detailed history is essential before considering such a drastic measure.
Correct Answer is A
Explanation
A. Stands on one foot for a few seconds: By age 3, children typically begin to develop the ability to stand briefly on one foot, although they may not be able to maintain balance for an extended period.
B. Skips and hops on one foot: Skipping and hopping on one foot are more advanced gross motor skills that usually develop around ages 4 to 5, so it would be less expected for a 3-year-old.
C. Walks backwards heel to toE. Walking backwards heel to toe requires a higher level of coordination and balance and is usually mastered later in childhood, typically around ages 4 to 6.
D. Has a vocabulary of 1,500 words: While vocabulary development varies among children, a vocabulary of 1,500 words would be advanced for a 3-year-old. Most children at this age have a vocabulary of around 200 to 1,000 words.
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