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. 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.
Correct Answer is A
Explanation
A. The toddler's anterior fontanel is not fully closeD. The closure of the anterior fontanel typically occurs by around 18 months of age. If the fontanel is still open at 3 years old, it may indicate a delay in normal development and could be a cause for concern. The nurse should further assess this finding and consider follow-up with the healthcare provider.
B. The toddler gained 3 in in height since last year: Growth in height is expected during early childhood, and a gain of 3 inches over a year is within the normal range for a 3-year-old.
C. The toddler gained 4 lb in weight since last year: Weight gain is also expected during early childhood, and a gain of 4 pounds over a year is within the normal range for a 3-year-old.
D. The circumference of the child's head increased 1 in since last year: Head circumference typically increases during early childhood as the brain grows, and a 1-inch increase over a year is within the normal range for a 3-year-old.
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