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 C

Explanation

A. Explaining that temporary burning at the IV site may occur is important for informing the client about potential side effects but does not address the specific risk associated with vesicant chemotherapeutic agents.

B. Applying a topical anesthetic at the infusion site for burning is not typically indicated during the administration of vesicant chemotherapeutic agents. While it may provide some comfort, it does not address the risk of extravasation.

C. Assessing the IV site frequently for signs of extravasation is essential during the administration of vesicant chemotherapeutic agents. Vesicants can cause tissue necrosis and damage if they leak into surrounding tissues. Early detection of extravasation allows for prompt intervention to minimize tissue damage.

D. Monitoring capillary refill distal to the infusion site is important for assessing peripheral perfusion but does not specifically address the risk of extravasation associated with vesicant chemotherapeutic agents.

A. Core strengthening. B. Aerobic exercise. C. Weight-bearing exercise. D. Muscle stretching and toning.

Correct Answer is C

Explanation

A. Core strengthening. While important for overall health, core strengthening is not as directly effective for osteoporosis prevention as weight-bearing exercise.
B. Aerobic exercise. Aerobic exercise is beneficial for cardiovascular health but does not have the same bone-strengthening effect as weight-bearing exercise.
C. Weight-bearing exercise. Weight-bearing exercises, such as walking, jogging, and strength training, are essential for maintaining bone density and preventing osteoporosis.
D. Muscle stretching and toning. Stretching and toning are important for flexibility and muscle health but do not significantly impact bone density compared to weight-bearing exercises.

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An infant is unresponsive and gasping for breath. Prior to starting CPR, which site should the nurse palpate for a pulse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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