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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Every 5 minutes for 30 minutes is crucial after paracentesis to closely monitor for signs of hypovolemia, such as a sudden drop in blood pressure. After this initial intensive monitoring period, the frequency can be reduced to every 4 hours to assess for any delayed effects or complications.

B. Every 5 minutes for one hour is a shorter duration of monitoring compared to option A and

may not provide adequate time to detect and respond to any significant changes in blood pressure that could occur after paracentesis, especially considering the volume of fluid removed.

C. Every 15 minutes for one hour, then every 1 hour for 2 hours provides frequent monitoring

initially, but the interval between assessments is too long after the first hour, potentially missing early signs of complications such as hypovolemia.

D. Every 1 hour for 2 hours does not provide sufficient frequency of monitoring, especially during the critical immediate post-paracentesis period when rapid changes in blood pressure can occur. This schedule may delay the detection and management of complications.

A. Improved visual acuity. B. Granulating tissue in foot ulcer. C. Full volume of pedal pulses. D. Reduced level of pain.

Correct Answer is D

Explanation

A. Improved visual acuity.
Pregabalin does not affect visual acuity. This medication is primarily used to manage neuropathic pain.

B. Granulating tissue in foot ulcer.
While important, this is not directly related to the effectiveness of pregabalin, which is prescribed for neuropathic pain, not wound healing.

C. Full volume of pedal pulses.
This reflects peripheral circulation but is not an indicator of the effectiveness of pregabalin for neuropathic pain.

D. Reduced level of pain.
This is the correct answer because pregabalin is used to treat neuropathic pain associated with diabetic peripheral neuropathy, and a reduction in pain indicates the medication is effective.

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