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. Allowing the child to adapt to the surroundings is not as critical as monitoring for complications.
B. Informing the child about the completion of the procedure is important for emotional support but does not address immediate post-procedure care needs.
C. Checking pedal pulses frequently is crucial after cardiac catheterization via the femoral artery to monitor for complications such as reduced blood flow or clot formation at the insertion site.
D. Encouraging the child to talk about the procedure is supportive but not the primary concern immediately following the procedure.
Correct Answer is D
Explanation
Rationale:
A. The conjunctivae can show signs of cyanosis but is not the most reliable indicator of central cyanosis.
B. Ear lobes may show peripheral cyanosis but are not reliable for central cyanosis.
C. The soles of the feet are not typically assessed for cyanosis in this context.
D. The oral mucosa is the most reliable indicator of central cyanosis, as it reflects the oxygenation status of the blood more accurately.