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. A bulging anterior fontanel is indicative of increased intracranial pressure, which can be a sign of severe dehydration in infants.
B. Bradypnea (slow breathing) is not typically associated with dehydration and may indicate other issues.
C. A capillary refill time of 3 seconds suggests delayed perfusion, but it is not as indicative of severe dehydration as other signs.
D. A 13% weight loss indicates severe dehydration, but the bulging fontanel is a more direct sign of the impact of dehydration on the infant's condition.
Correct Answer is B
Explanation
Rationale:
A. Telling the child that temper tantrums are unacceptable may not be effective, as toddlers may not fully understand this concept.
B. Ignoring temper tantrums is often recommended because giving attention to the tantrum can reinforce the behavior. Consistently ignoring the tantrum can help decrease their frequency over time.
C. While distraction can sometimes be effective, it may not work in the middle of a tantrum when the child is already upset.
D. Physically restraining the child is not recommended as it can escalate the situation and lead to further distress.