An infant is unresponsive and gasping for breath. Prior to starting CPR, which site should the nurse palpate for a pulse?
Left 5th intercostal space midclavicular line
Right carotid area
Over the brachial artery
Over the sternum
The Correct Answer is C
A. Left 5th intercostal space midclavicular line: Palpating the left 5th intercostal space midclavicular line is not appropriate for assessing pulse in an unresponsive infant. This location is typically used for cardiac auscultation and not for pulse assessment.
B. Right carotid area: Palpating the carotid artery is not recommended in infants due to the risk of causing injury to the delicate structures of the neck, including the
airway and blood vessels.
C. Over the brachial artery: The brachial artery is the preferred site for assessing pulse in infants. It is located in the inner aspect of the upper arm and can be easily palpated. In an unresponsive infant, the brachial pulse should be assessed before
initiating CPR.
D. Over the sternum: Palpating over the sternum is not an appropriate site for pulse assessment in infants. The sternum is a bone and does not contain any major arteries suitable for pulse palpation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Avoid stimulation of the breasts and wear a tight bra: This is the most appropriate recommendation for a bottle-feeding postpartum client with breast engorgement. Minimizing breast stimulation and wearing a supportive, tight-fitting bra can help reduce milk production and alleviate discomfort.
B. Express a small amount of breast milk by hand: This action may provide temporary relief but can stimulate further milk production, which is not advisable for a client who is bottle-feeding and attempting to suppress lactation.
C. Place warm packs on both breasts: Warmth can promote milk flow and is typically recommended for breastfeeding mothers. For a bottle-feeding client, cold compresses are more appropriate to reduce engorgement.
D. Take a prescribed analgesic and expose breasts to air: While analgesics can help manage discomfort, exposing the breasts to air has no therapeutic benefit for engorgement and may increase discomfort. This is not the best overall recommendation.
Correct Answer is C
Explanation
A. Offer the client oral fluids. Offering fluids is important but is not directly related to turning the client or managing the urinary catheter.
B. Assess the breath sounds. Assessing breath sounds is beyond the scope of practice for a UAP.
C. Empty the urinary drainage bag. This action helps maintain catheter function and reduces the risk of infection by preventing urine from backing up in the bladder.
D. Feed the client a snack. Feeding the client is important but is not related to turning the client or managing the urinary catheter.
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