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?
A.
Apex of the heart
B.
Carotid artery
C.
Brachial artery
D.
Radial artery
The Correct Answer and Explanation is:
The correct answer is A. Apex of the heart.
In infants, the most reliable site to assess heart rate is the apex of the heart. This location, also known as the apical pulse, is typically auscultated using a stethoscope. The apex of the heart is located in the left fifth intercostal space, slightly below the nipple line. This site provides a clear and direct measure of the infant’s heart rate, which is particularly important in this age group because peripheral pulses may not be as strong or easily palpated due to the small size of the infant’s vessels.
Rationale for Other Options:
- B. Carotid artery: While the carotid artery is a reliable pulse site in older children and adults, it is not ideal for infants. Palpating the carotid artery in an infant can be difficult and may pose a risk of compressing the artery, potentially leading to bradycardia or altered blood flow to the brain.
- C. Brachial artery: The brachial artery is commonly used for assessing a pulse during infant CPR, but it is not the preferred site for routine heart rate assessment. Palpating the brachial artery can be challenging, and the pulse may not always provide an accurate reflection of the heart’s rate.
- D. Radial artery: In adults and older children, the radial pulse is often used to assess heart rate. However, in infants, the radial pulse is typically weak and difficult to palpate, making it an unreliable site for accurate heart rate measurement.
Importance of Apical Pulse in Infants:
The apical pulse is the most accurate indicator of heart rate in infants due to their rapid heart rates and developing cardiovascular system. In infants, heart rates are typically higher than in older children or adults, often ranging between 100 to 160 beats per minute. Using the apical pulse allows healthcare providers to assess the infant’s cardiac function and detect any abnormalities, such as irregular rhythms or murmurs, which might be missed with peripheral pulse palpation.
Thus, auscultation of the apical pulse is the preferred method for accurately measuring an infant’s heart rate.