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 ["A","B","E","F"]
Explanation
Rationale:
A. Given the client’s symptoms (right lower quadrant pain, nausea, fever) and elevated WBC count indicating a possible infection, the provider may prescribe IV antibiotics. This is especially important if there is a concern for appendicitis or another bacterial infection.
B. The client may need to be kept NPO (nil per oral) in preparation for possible surgery or diagnostic imaging to prevent complications such as aspiration if surgery is needed.
C. Promethazine is an antiemetic, but the priority in this case would be addressing the underlying condition (likely appendicitis) rather than just managing symptoms. However, it might be used later for symptomatic relief.
D. Acetaminophen may be used for pain management, but with a suspected surgical condition, addressing the root cause is more critical. Pain management will likely be considered after the primary issue is addressed.
E. With symptoms and lab results suggestive of appendicitis, the client may require surgery. Informed consent is necessary before any surgical procedure.
F. An abdominal ultrasound is commonly used to assess for appendicitis in children and can help confirm the diagnosis by visualizing the appendix and assessing for inflammation.
G. Enemas are not indicated in this case and could be harmful. They are not recommended for abdominal pain with a possible surgical condition like appendicitis.
Correct Answer is A, B, C, D
Explanation
Rationale:
A. Inspection: The nurse begins with a visual examination of the abdomen, looking for any abnormalities in skin color, shape, or movement.
B. Auscultation: Next, the nurse listens to the bowel sounds using a stethoscope. This step is performed before palpation to avoid altering the bowel sounds.
C. Superficial palpation: The nurse gently presses the surface of the abdomen to assess for any tenderness, distension, or masses.
D. Deep palpation: Finally, the nurse applies deeper pressure to feel for any deeper structures or masses within the abdomen.