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","E","G"]
Explanation
A. Involve your mother in the decision-making process.
Involving the client in decision-making can help maintain her autonomy, reduce feelings of
helplessness, and potentially decrease the daughter's caregiver burden by sharing responsibility.
B. Moving your mother into a care facility will show her that you do not love her.
This statement is incorrect and could exacerbate feelings of guilt and stress in the caregiver. Decisions about care facilities should be based on the best interests of both the client and the caregiver, not on guilt or misconceptions about love.
C. It is okay not to love or like your mother when you are caring for her.
This statement might be misunderstood and could increase feelings of guilt and stress. It's more helpful to acknowledge that caregiving can be challenging and that it's normal to have mixed emotions.
D. You made a promise to your mother that you need to keep.
This statement could increase stress by suggesting that the caregiver has no options or flexibility, potentially exacerbating feelings of obligation and guilt.
E. Take time for yourself and the other relationships that you care about.
Taking time for self-care and maintaining other relationships is crucial for reducing caregiver stress and preventing burnout.
F. Saying "no" to things involving the care of your mother is a selfish action.
This statement is incorrect and could increase feelings of guilt and stress. It's important for caregivers to set boundaries and understand that it's okay to say "no" sometimes to maintain their well-being.
G. Helping your mother should be easier than raising a child.
This statement is misleading. Caregiving for an elderly parent can be as demanding, if not more so, than raising a child. It's important to recognize and validate the challenges of caregiving to provide appropriate support.
H. Avoid discussion of negative situations that may occur in the future.
This statement is not advisable. Open and honest communication about potential challenges is important for planning and reducing stress through preparedness.
Correct Answer is C
Explanation
A. While repeated requests for attention from the nurse might indicate distress, they are not necessarily indicative of potential aggression or disruptive behavior.
B. Periodic sighing and shaking the head could suggest the client's emotional state, but they are not as indicative of potential aggression or disruptive behavior as argumentativeness and profanity.
C. Monitoring for argumentativeness and the use of profanity is crucial as they can escalate into disruptive or potentially aggressive behavior. It's important to assess the client's agitation level and ensure the safety of both the client and others on the mental health unit.
D. Decreased activity level and a change in affect may suggest a worsening of the client's mental state but are not immediate concerns in terms of safety on the unit.
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