Difficulty: Medium
Average Score: 80%
Simulated
Passage / Scenario
Infant's vital signs.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?
Correct answer
A
Rationale
The correct answer is A: Apex of the heart. When assessing an infant's heart rate, the apex of the heart is the most accurate site due to the infant's small size and thin chest wall, allowing for a more direct and precise measurement of the heartbeat. The apex is located at the point of maximal impulse (PMI) on the left side of the chest, typically at the 4th or 5th intercostal space in the midclavicular line. This location provides the nurse with the closest proximity to the heart, enabling the detection of subtle changes in heart rate. Brachial, radial, and carotid arteries are used to assess pulse, not heart rate, making choices B, C, and D incorrect in this context.