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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?

A.

Brachial artery

B.

Radial artery

C.

Apex of the heart

D.

Carotid artery

Answer and Explanation

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 B

Explanation

Rationale:

A. Hypotension is not typically associated with coarctation of the aorta; it more often leads to hypertension in the upper body.

B. Unequal pulses in the upper and lower extremities are a classic sign of coarctation of the aorta, as the obstruction typically affects blood flow to the lower body.

C. Excessive crying is not a specific indicator of coarctation of the aorta and can occur due to various reasons.

D. A diastolic murmur is not a primary indicator of coarctation of the aorta; it is more associated with other cardiac conditions.

Correct Answer is D

Explanation

Rationale:

A. The Doll's eye reflex is expected to be negative in older infants. It is present in newborns but should be absent by 2 months of age.

B. The Crawl reflex, which involves the infant moving forward when placed on their stomach, should disappear by 6-8 months. A negative reflex at 9 months is expected.

C. The Babinski reflex, where the toes fan out when the sole of the foot is stroked, is normal in infants up to 12-18 months.

D. The Moro reflex, or startle reflex, should disappear by 4-6 months of age. A positive Moro reflex at 9 months indicates a delay in neurological development and requires further evaluation.

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