A nurse is preparing to measure an infant's vital signs. The nurse should use which of the following sites to assess a heart rate?
Brachial artery
Radial artery
Apex of the heart
Carotid artery
The Correct Answer is A
Rationale:
A. The brachial artery is commonly used to assess the heart rate in infants due to its accessibility and the ease of palpation in smaller limbs.
B. The radial artery is not typically used in infants because it is less accessible and not as easily palpated in this age group.
C. While the apex of the heart is where heart sounds are best auscultated, it is not used to palpate the pulse in infants.
D. The carotid artery is not typically used for assessing the heart rate in infants due to the risk of applying excessive pressure.
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Correct Answer is D
Explanation
Rationale:
A. Seizure precautions are necessary due to the risk of seizures in bacterial meningitis.
B. A private room is necessary to reduce the spread of infection to others.
C. Semi-Fowler's position helps reduce intracranial pressure and is appropriate in managing bacterial meningitis.
D. Measuring head circumference every shift is not typically required for a 6-year-old with bacterial meningitis, as it is more relevant in infants where rapid head growth could indicate increased intracranial pressure.
Correct Answer is C
Explanation
Rationale:
A. A decreased respiratory rate is not a typical sign of pain in an infant and may indicate other issues.
B. Increased formula consumption is not a specific indicator of pain and could be related to other factors like hunger or comfort.
C. Increased crying episodes are a common sign of pain in infants, as they often use crying to express discomfort or distress.
D. Decreased heart rate is not typically associated with pain and may indicate other conditions.