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. A storybook may provide comfort and information but is less interactive in helping the child process the experience of injections.
B. Playing in the playroom is beneficial for normalizing hospital stays but does not directly address the child’s distress regarding injections.
C. A video game can be a good distraction but does not provide therapeutic engagement with the fear or anxiety related to injections.
D. Allowing the child to play with a needleless syringe and a doll is therapeutic as it gives the child a sense of control and understanding of the injection process, helping to reduce fear and anxiety.
Correct Answer is B
Explanation
Rationale:
A. Telling the child that temper tantrums are unacceptable may not be effective, as toddlers may not fully understand this concept.
B. Ignoring temper tantrums is often recommended because giving attention to the tantrum can reinforce the behavior. Consistently ignoring the tantrum can help decrease their frequency over time.
C. While distraction can sometimes be effective, it may not work in the middle of a tantrum when the child is already upset.
D. Physically restraining the child is not recommended as it can escalate the situation and lead to further distress.