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 A

Explanation

A. Correct. A hemoglobin level of 14.9 g/dL indicates that the client has an adequate amount of oxygen-carrying capacity in the blood, which is the goal of blood transfusion therapy.

B. Incorrect. A WBC count of 12,000/mm3 is slightly elevated and may indicate an infection or inflammation, which are not related to blood transfusion therapy.

C. Incorrect. A potassium level of 48 mEq/L is dangerously high and may cause cardiac arrhythmias, muscle weakness, or paralysis. This is not an expected outcome of blood transfusion therapy and may indicate hemolysis or renal impairment.

D. Incorrect. A BUN level of 18 mg/dL is within the normal range and does not reflect the effectiveness of blood transfusion therapy.

A. The LPN and AP lower the side rails before lifting the client up in bed. B. Prior to lifting the client, the LPN and AP raise the bed to waist level. C. The LPN and the AP grasp the client under his arms to lift him up in bed. D. The LPN and the AP ask the client to flex his knees and push his heels into the bed as they lift.

Correct Answer is C

Explanation

A. The LPN and AP lower the side rails before lifting the client up in bed is incorrect. This is a safe practice that prevents injury to the client and staff by providing more space for movement and reducing the risk of falling.

B. Prior to lifting the client, the LPN and AP raise the bed to waist level is incorrect. This is a safe practice that prevents injury to the client and staff by reducing the need for bending and lifting.

C. The LPN and the AP grasp the client under his arms to lift him up in bed is correct. This is an unsafe practice that can cause injury to the client's shoulders, neck, and axillae by applying excessive pressure and friction. The LPN and AP should use a draw sheet or a mechanical lift device to move the client up in bed.

D. The LPN and the AP ask the client to flex his knees and push his heels into the bed as they lift is incorrect. This is a safe practice that encourages active participation from the client and reduces the workload for the staff by using leverage.

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

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