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. Assessing the erythematous rash is important, as it can indicate the presence of erythema marginatum, a common symptom of rheumatic fever, but it is not the priority.
B. Auscultating the rate and characteristics of the child's heart sounds is the priority assessment because acute rheumatic fever can cause carditis, which affects the heart valves and can lead to serious complications. Early detection of any cardiac involvement is crucial for timely intervention and management.
C. Assessing joint pain is necessary for comfort and symptom management but does not take precedence over potential cardiac complications.
D. Identifying parental anxiety is important for providing emotional support but is not the immediate priority in managing the child's acute condition.
Correct Answer is B
Explanation
Rationale:
A. Obtaining a blood culture is important but is not the immediate priority when a transfusion reaction is occurring.
B. Stopping the transfusion is the first step in managing a transfusion reaction to prevent further exposure to the allergen or irritant causing the symptoms.
C. Slowing the transfusion rate might not be sufficient if a reaction is occurring; stopping it is crucial.
D. Providing a diuretic is not relevant to the management of an acute transfusion reaction.