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 C
Explanation
Rationale:
A. Erikson's stage of initiative versus guilt typically occurs during the preschool years (3-6 years), not the toddler stage.
B. Imaginary playmates are more characteristic of the preschool years rather than the toddler stage.
C. Toddlers are in Erikson's stage of autonomy versus shame and doubt, characterized by negative behaviors as they assert independence and develop autonomy.
D. Demonstrations of sexual curiosity become more pronounced during the preschool years and are less typical in the toddler stage.
Correct Answer is C
Explanation
Rationale:
A. Loosening restrictive clothing is important for ensuring the child’s comfort and preventing injury, but it is not the immediate priority.
B. Placing a pillow under the child’s head can help prevent head injury during a seizure, but positioning the child is more urgent to prevent aspiration.
C. Positioning the child side-lying is the priority because it helps maintain an open airway and reduces the risk of aspiration of vomit during the seizure. Protecting the airway is the most critical intervention in this scenario.
D. Clearing the area of hazards is important to prevent injury during the seizure, but it is secondary to ensuring the child's airway is protected.