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 B
Explanation
Rationale:
A. These vital signs are generally within expected ranges for a 2-year-old child.
B. A blood pressure of 79/40 mm Hg is low for a 2-year-old, and the elevated heart rate of 135/min and increased respirations suggest that the child may be experiencing significant distress or volume depletion, requiring immediate attention.
C. These vital signs are within normal limits for a 2-year-old child.
D. Although the blood pressure is on the lower end of normal and heart rate is slightly elevated, these findings are less concerning than option B.
Correct Answer is C
Explanation
Rationale:
A. Gastritis in the father is unrelated to rheumatic fever, which is linked to streptococcal infections, not gastrointestinal issues.
B. Chickenpox, caused by the varicella-zoster virus, is not related to rheumatic fever.
C. A sibling who had a sore throat 3 weeks ago is significant because rheumatic fever often follows an untreated or inadequately treated streptococcal throat infection. Recognizing a recent history of streptococcal infection is key to understanding the source of the child's rheumatic fever.
D. Fifth disease, caused by parvovirus B19, is also unrelated to rheumatic fever.