Peds-Elsevier Evolve Clinical Skills for Nursing Collection

When teaching the family members of a 4-year-old patient how to assess a radial pulse, which technique should the health care team member recommend? A. "Place the tips of your first two fingers over the groove along the thumb side of your child's inner wrist." B. "Place the tip of your thumb over the groove along the thumb side of your child's inner wrist." C. "Place the tips of the first two fingers over the groove opposite the thumb side of your child's inner wrist." D. "Place the tip of your thumb over the groove opposite the thumb side of your child's inner wrist."

A. "Place the tips of your first two fingers over the groove along the thumb side of your child's inner wrist." Rationale: The radial pulse site is located over the groove along the thumb side (radius) of the patient's inner wrist, and fingertips are the most sensitive parts of the hand to palpate the arterial pulse. The thumb has pulsations that may interfere with accuracy and is not recommended. The groove opposite the thumb side of the patient's inner wrist is the ulnar site, which is not appropriate.

The health care team member knows that the strength of a peripheral pulse correlates how? A. Directly proportional to the SV B. Inversely proportional to the SV C. Directly proportional to the patient's age D. Inversely proportional to the patient's age

A. Directly proportional to the SV Rationale: The strength or amplitude of a pulse reflects the volume of blood ejected against the arterial wall with each heart contraction, also called SV. If the heart's SV decreases, the pulse often becomes weak and difficult to palpate. In contrast, a full bounding pulse is an indication of increased SV. Although infants may have somewhat weaker pulses compared with older pediatric patients, the relationship of SV to the peripheral pulse remains the same for all ages.

The health care team member notes that the radial pulse of a 6-year-old patient is irregular. What is the most appropriate intervention? A. Count the radial pulse for 30 seconds and multiply by two. B. Count the radial pulse for a full 60 seconds. C. Count the apical pulse for 30 seconds and multiply by two. D. Count the femoral pulse for a full 60 seconds.

B. Count the radial pulse for a full 60 seconds. Rationale: In this instance, counting for 1 full minute (a longer time period) ensures a more accurate count of the actual pulse per minute. An inefficient contraction of the heart may fail to transmit a pulse wave, resulting in an irregular pulse, or the patient may have an actual cardiac arrhythmia. Counting the apical pulse gives information about the actual beating of the heart per minute but does not tell about perfusion. Depending on the type of arrhythmia or the cardiac problem present, there may be a mismatch between the apical rate and the radial rate. The nonconducted beats (inefficient contractions) would result in irregular peripheral pulses, even though the apical pulse may sound regular.

Which assessment findings would the health care team member recognize as indicative of early shock? A. Tachycardia and increased peripheral perfusion B. Tachycardia and decreased peripheral perfusion C. Bradycardia and increased peripheral perfusion D. Bradycardia and decreased peripheral perfusion

B. Tachycardia and decreased peripheral perfusion Tachycardia accompanied by decreased peripheral perfusion is an early sign of shock. As shock progresses, peripheral perfusion continues to deteriorate. Shock is the state of not enough blood flow to the tissues of the body as a result of problems with the circulatory system; therefore, increased perfusion would not be associated with suspected shock. Bradycardia and decreased peripheral perfusion would be suggestive of late shock.

A peripheral IV line has just been inserted in a 4-year-old patient, and it is now time to obtain routine vital signs. What action best reflects the appropriate care? A. Assessing an apical pulse rate B. Waiting before assessing pulse rate C. Immediately assessing pulse rate D. Assessing the pulse when the patient is ready

B. Waiting before assessing pulse rate Rationale: Waiting to assess the pulse after an external stimulus or activity (such as insertion of an IV line), to allow the pulse to return to baseline, is recommended practice. Fear and anxiety elevate heart rate, as do many other things, including some medications, fever, and exercise. Although heart rates are often assessed during and after procedures, those numbers reflect the patient's response to the stimulus, not the baseline. The apical pulse rate should match the radial rate and would not reflect an accurate rate. Routine vital signs are intended to reflect the patient's baseline at that time, not the response to stimulus. Although interacting with the patient in a comforting and cooperative manner is important, some pediatric patients would never say they are ready to have an assessment done.

How would the health care team member document a full, increased pulse amplitude? A. 1+ B. 2+ C. 3+ D. 4+

C. 3+ Rationale: A full, increased amplitude or strength of pulse is documented as 3+. The strength or amplitude of a pulse reflects the volume of blood ejected against the arterial wall with each heart contraction. This scale is subjective, and the health care team member might consider having another team member assess the patient at the same time. A 0+ strength is absent or not palpable; 1+ is diminished, barley palpable; 2+ is expected; 4+ is bounding aneurysmal.

Which position best facilitates assessment of a patient's radial pulse? A. Flexing the patient's arm and palpating firmly B. Flexing the patient's arm and wrist C. Relaxing the patient's arm and extending the wrist D. Relaxing the patient's arm and palpating firmly

C. Relaxing the patient's arm and extending the wrist Rationale: A relaxed position of the lower arm and extension of the wrist permits full exposure of the artery to palpation. Flexion may decrease the peripheral pulse. The pulse is more accurately assessed with moderate pressure. Too much pressure impairs blood flow and occludes the pulse.

While assessing a patient with a left forearm cast, the health care team member notes a weakened radial pulse compared to the other arm. Which action would the team member take? A. Document the findings and offer pain medication. B. Document the findings and offer a warm pack to improve perfusion. C. Document the findings and use right radial pulse for future assessment. D. Document the findings and notify the practitioner immediately.

D. Document the findings and notify the practitioner immediately. Rationale: The health care team member should document the findings and notify the practitioner immediately. If a peripheral pulse distal to an injured or treated area of an extremity feels weak on palpation, the volume of blood reaching tissues below the affected area may be inadequate, and an intervention may be needed (e.g., replacing the cast on a fractured arm if the pulses distal to the cast are decreasing). Neither pain medication nor a warm pack will improve a weakened pulse that is likely related to a cast restricting blood flow. Switching to a right radial assessment is inappropriate; doing so will not address the potential complication associated with a weakened left radial pulse.

During the assessment of a 14-month-old patient, why should the apical pulse rate be checked rather than radial pulse rate? A. Radial pulse rates are used in pediatric patients receiving digitalis preparations. B. Irregular pulse rates are common for a patient this age. C. Apical pulse rates give valuable information about perfusion. D. Radial pulse rates can be difficult to palpate in a patient this age.

D. Radial pulse rates can be difficult to palpate in a patient this age. Rationale: Apical pulse rates are more reliable in patients younger than 2 years old because their rapid heart rate may make accurate counts of their pulse rates difficult. Although young pediatric patients may have a sinus arrhythmia in which fluctuations in the heart rate correspond to the respiratory cycle, an irregular heart rate that is independent of respirations may indicate an underlying rhythm disturbance and is not considered normal. An apical pulse assessment allows evaluation of the heart rate but gives no information regarding perfusion; this comes from assessing peripheral pulses along with other signs. A pediatric patient receiving digitalis preparations may have an underlying cardiac arrhythmia or decreased CO and should, therefore, have an apical pulse rate assessment.

Which heart rhythm would the health care team member recognize in a patient who has a fluctuation in the radial pulse that corresponds to the respiratory cycle (increases with inspiration and slows with expiration)? A. Normal sinus rhythm B. Sinus bradycardia C. Supraventricular tachycardia D. Sinus arrhythmia

D. Sinus arrhythmia Patients may have a sinus arrhythmia, which is a fluctuation in the heart rate that corresponds to the respiratory cycle. The pulse increases with inspiration and slows down with expiration. Normal sinus rhythm reflects a normal heart rhythm. Sinus bradycardia is a slower than the expected heart rate. Supraventricular tachycardia is an abnormally fast heart rate.