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 C
Explanation
A. Discouraging daily fruit juice intakE. While excessive fruit juice intake can contribute to weight gain and dental caries, it's not the priority nursing intervention in this scenario.
B. Increasing the number of breastfeedings: Breastfeeding frequency may be appropriate, but without more information about the child's current feeding patterns and growth trajectory, it's not the priority intervention.
C. Discussing the child's feeding patterns: This is the priority intervention because it allows the nurse to assess the child's current feeding habits, including frequency, duration, and type of feedings, to determine if they are appropriate for the child's growth and development.
D. Talking about solid food consumption: Solid food introduction is typically recommended around 6 months of age, but the priority in this scenario is to assess the current feeding
patterns before discussing solid food introduction.
Correct Answer is A
Explanation
A. "I will give him a pacifier during feeding time.": Giving a pacifier during feeding time may interfere with the infant's ability to coordinate sucking, swallowing, and breathing, especially if
they are receiving nutrition through a nasogastric tube. This response indicates a need for further teaching because pacifiers during feeding time could potentially disrupt the infant's feeding
pattern and may not be appropriate in this situation.
B. "We need to make sure he doesn't lose the desire to eat by mouth.": This response
demonstrates an understanding of the importance of maintaining the infant's oral feeding skills and indicates appropriate knowledge about promoting oral feeding while using a nasogastric
tube.
C. "We need to keep feeding time very quiet.": Keeping feeding time quiet can help reduce distractions and promote a calm environment, which may enhance feeding tolerance for the infant. This response reflects an understanding of strategies to facilitate feeding.
D. "Sucking produces saliva, which aids in digestion.": This response demonstrates knowledge about the benefits of sucking and saliva production during feeding, indicating an understanding of the infant's physiological needs during feeding.
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