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. Collecting all urine may be relevant in certain conditions, such as kidney function monitoring, but it is not specific to Wilms' tumor management.
B. Restrictions on venipuncture or blood pressure in a specific arm are relevant for conditions like lymphedema or post-mastectomy, not Wilms' tumor.
C. Contact precautions are necessary for infectious diseases, not applicable to Wilms' tumor.
D. Wilms' tumor is a renal tumor, and palpating the abdomen could potentially cause the tumor to rupture and spread malignant cells. Therefore, it is critical to avoid any abdominal palpation in these patients.
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.