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 D
Explanation
Rationale:
A. Developing autonomy is typically associated with increased independence and exploring new skills, not behaviors seen in a distressed or hospitalized child.
B. While anxiety may be present, the behavior of turning away and thumb-sucking more strongly suggests regression.
C. Resentment toward the mother would not typically result in the described behavior of thumb-sucking and turning away from the nurse.
D. Regression is when a child reverts to earlier behaviors, such as thumb-sucking, as a coping mechanism in response to stress or separation from the primary caregiver.
Correct Answer is A
Explanation
Rationale:
A. Recording an upper extremity blood pressure (in the arms) compared to a lower extremity blood pressure (in the legs) can help reveal coarctation of the aorta, as the condition often results in higher blood pressure in the upper body and lower pressure in the lower body.
B. Assessing for femoral pulses is important but may not reveal coarctation of the aorta unless there is significant obstruction.
C. Excessive crying is not a specific indicator of coarctation of the aorta.
D. While a cardiac murmur can be associated with various heart conditions, it is not the most definitive assessment for coarctation of the aorta.