The nurse is performing a physical assessment on a four-month-old infant.
The nurse is demonstrating an appropriate assessment technique by
The nurse is performing a physical assessment on a four-month-old infant.
The nurse is demonstrating an appropriate assessment technique by
A. auscultating the left 4th intercostal space, midclavicularly for 60 seconds.
[54%]
B. palpating the left 5th intercostal space. midclavicular for 30 seconds
[5%]
C. palpating the brachial pulse for 60 seconds.
[39%]
D. auscultating the radial pulse for 30 seconds.
[2%]
Statistics
Subject/Lesson
Subject
Child Health
Lesson
Cardiovascular
Client Need
Test Plan
Health Promotion and Maintenance
Related Topic
Techniques of Physical Assessment
Item Type
Item Type
Analysis
Explanation
Choice A is correct. Auscultating the apical pulse for 60 seconds is the most accurate way to assess the heart rate of a 4-month-old infant. The nurse should auscultate instead of palpate because it is difficult to accurately count the pulse rate via palpation on a moving 4-month-old. Due to irregularities, a full minute should be auscultated to ensure the most accurate heart rate is recorded. The apex is the best location for this assessment, and in infants, it is located at the 4th intercostal space (ICS) to the left of the sternum at the midclavicular line. In adults, the apex is located at the 5th intercostal space (ICS) to the left of the sternum at the midclavicular edge.
Choice B is incorrect. It is not the most accurate to palpate the apical pulse; the nurse should auscultate instead. Also, the apex is located in the infant's left 4th intercostal space, not the 5th intercostal space. Additionally, it is most accurate to auscultate for 60 seconds, not just 30 seconds.
Choice C is incorrect. The brachial pulse is not the most accurate location for assessment of the heart rate in a 4-month-old infant. Auscultation of the apical pulse should be performed.
Choice D is incorrect. The radial pulse is not the most accurate location for assessment of the heart rate in a 4-month-old infant. Auscultation of the apical pulse should be performed.
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2 Key Topics
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Additional Info
