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 ["100"]
Explanation
- Total volume of the infusion: 50 mL (saline bag)
- Infusion time: 30 minutes = 0.5 hours (convert minutes to hours)
- We don't need the concentration of gentamicin for this calculation because we're only interested in the total volume delivered per hour.
- Flow rate: Since all the medication is delivered within the infusion time, the flow rate is equal to the total volume divided by the infusion time.
Flow rate (mL/hour) = Total volume (mL) / Infusion time (hours)
Flow rate = 50 mL / 0.5 hours Flow rate = 100.0 mL/hour
Therefore, the nurse should set the pump to deliver 100.0 mL/hour to infuse the 60 mg of gentamicin over 30 minutes.
Correct Answer is B
Explanation
A. While scheduling a client and family conference may be necessary to discuss the plan of care, the immediate concern is to determine the type of advance directive the client has and whether it includes preferences regarding resuscitation.
B. This is the most appropriate action because it addresses the family member's concern and ensures that the client's wishes regarding resuscitation are understood and followed.
C. While checking for a DNR bracelet is important, it does not address the family member's question about why the code was called despite the client having a living will.
D. This statement is incorrect. Living wills can guide decision-making regarding end-of-life care, including resuscitation, depending on the legal requirements and documentation in place.
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