Health Promotion and Maintenance
40. A nurse prepares to administer digoxin to an infant. Where is the most appropriate location for the nurse to assess the infant's heart rate?
Health Promotion and Maintenance
40. A nurse prepares to administer digoxin to an infant. Where is the most appropriate location for the nurse to assess the infant's heart rate?
Test-Taking Tip
The correct response does not vary with the child's age. A nurse must assess the apical heart rate, not simply the pulse rate, prior to digoxin administration.
Content Area: Child Health, Cardiovascular; Integrated Process: Nursing Process, Assessment; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Pharmacological and Parenteral Therapies/Medication Administration
Health Promotion and Maintenance
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Answer 1 is correct because, prior to digoxin administration, all children should have their apical pulse assessed by auscultation at the apex of the heart. The heartbeats are best heard at the apex of the heart, making this the best location for assessing the heart rate. Answer 2 is incorrect because this location is best for assessing the brachial pulse. This is not the best location for assessing heart rate because the brachial artery may be difficult to palpate, leading to inaccurate assessment. Answer 3 is incorrect because this location is best for assessing the radial pulse. This is not the best location for assessing heart rate because the radial artery may be difficult to palpate, leading to inaccurate assessment. Answer 4 is incorrect because heart beats are best heard at the apex of the heart, not the base of the heart, making the apex the best location for auscultation and assessment of heart rate.
