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
Explanation
Rationale:
A. The knee-chest position increases systemic vascular resistance, which helps to divert more blood to the pulmonary circulation, improving oxygenation in a child experiencing a "tet spell" or hypercyanotic episode.
B. The prone position does not help in relieving cyanosis and dyspnea in Tetralogy of Fallot.
C. The supine position with the head turned does not assist in improving oxygenation during a cyanotic episode.
D. The semi-Fowler's position may aid breathing but is less effective than the knee-chest position in managing cyanotic spells.
Correct Answer is B
Explanation
Rationale:
A. Encouraging deep breathing is important for preventing pulmonary complications but is not the priority in managing a vaso-occlusive crisis.
B. Maintaining hydration through intravenous fluids is the priority as it helps to reduce blood viscosity and prevent further sickling of cells, which is critical in managing a vaso-occlusive crisis.
C. Active range-of-motion exercises are important but are not a priority during an acute vaso-occlusive crisis.
D. A protein-rich diet supports overall health but is not immediately relevant to the acute management of a vaso-occlusive crisis.