The nurse on the pediatric unit is assigned to care for four ...

[jessicacav]

The nurse on the pediatric unit is assigned to care for four children. One of the children is 18 months old and the rest are 3, 4, and 4-1/2 years old.
 
  The youngest is in for observation, the 3-year-old has a cardiac problem, and the two older children are in for tests. After a report the nurse takes the children's vital signs. The nurse would need to take the pulses in which of the following ways? a. radial pulse on all the children
  b. radial on the two older children and apical on the 18-month-old and the child with a cardiac problem
  c. apical on all children under 5
  d. apical only on the child with a cardiac problem

Question 2

The nurse is preparing to count the respirations of an infant. The nurse will count the respirations for:
 
  a. 15 seconds, watching the chest c. 1 minute, watching the chest
  b. 30 seconds, watching the abdomen d. 1 minute, watching the abdomen

[tennis14576]

Answer to Question 1

B

Feedback
A Incorrect. A radial pulse can be obtained on children over 2 years of age, but not the 18 month old nor the child with a cardiac problem.
B Correct. An apical pulse should be taken on neonates, infants and young children (under 2 years of age) and on all children with cardiac problems or on digitalis preparations.
C Incorrect. An apical pulse should be taken on all children under 2 years of age, not 5.
D Incorrect. Apical pulse should be taken on the child under 2 years of age and the child with a cardiac problem.

Answer to Question 2

D

Feedback
A Incorrect. The nurse will not count the respirations for 15 seconds, watching the chest of an infant.
B Incorrect. The nurse will not count the respirations for 30 seconds, watching the abdomen, but count for one minute.
C Incorrect. The nurse will not count the respirations for 1 minute, watching the chest in an infant.
D Correct. The nurse counts the number of respirations per minute early in the assessment then the child is most cooperative and not crying, remembering for infants and toddlers to observe the expansion of the abdomen.