A nurse is assessing a newborn's heart rate. Which of the following actions should the nurse take?

Assess the apical pulse while the newborn is crying.

Palpate the radial pulse for 30 seconds.

Listen to the apical pulse while palpating the radial pulse.

Auscultate the apical pulse at least 1 min.

Answer and Explanation

The Correct Answer is D

A is incorrect because assessing the apical pulse while the newborn is crying can result in an inaccurate measurement due to increased heart rate and respiratory rate.

B is incorrect because palpating the radial pulse for 30 seconds is not appropriate for a newborn as it can be difficult to locate and count accurately.

C is incorrect because listening to the apical pulse while palpating the radial pulse is not necessary for a newborn and can be confusing and time-consuming.

D is correct because auscultating the apical pulse at least 1 min is the best way to assess a newborn's heart rate as it provides an accurate and reliable measurement.

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Correct Answer is D

Explanation

A. The client is taking numerous deep, measured breaths. This is not an indication of potential violence, but rather a coping strategy to calm down and regulate emotions.

B. The client is calmly telling their partner that "the staff here is so controlling." This is not an indication of potential violence, but rather a expression of frustration or dissatisfaction with the treatment setting.

C. The client is sitting with their head in their hands and appears to be crying. This is not an indication of potential violence, but rather a sign of sadness or distress.

D. The client is pacing around the chair in which their partner is sitting. This is an indication of potential violence, as it shows restlessness, agitation, and possible intimidation of the partner.

A. Organizing the work environment B. Delegating assigned tasks appropriately C. Making a list of activities to complete D. Rewarding yourself for accomplishing goals

Correct Answer is C

Explanation

A. Incorrect. Organizing the work environment is an important step of the time management process, but it is not the priority. The nurse manager should first identify the activities that need to be done before organizing them.

B. Incorrect. Delegating assigned tasks appropriately is an important step of the time management process, but it is not the priority. The nurse manager should first determine which tasks can be delegated and which ones require their direct involvement before assigning them to others.

C. Correct. Making a list of activities to complete is the priority step of the time management process, as it helps the nurse manager to identify and prioritize their goals and responsibilities.

D. Incorrect. Rewarding yourself for accomplishing goals is an important step of the time management process, but it is not the priority. The nurse manager should first complete the tasks that are essential and urgent before rewarding themselves for their achievements.

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