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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "Perhaps you think the ECT is dangerous, but I've seen it have good results." This response is dismissive of the client's concerns and implies that the nurse knows better than the client.
B. "You have the right to change your mind about this procedure at any time." This response respects the client's autonomy and informs them of their rights.
C. "Everyone gets a little nervous about this procedure as the time for it approaches." This response minimizes the client's feelings and assumes that they are experiencing normal anxiety.
D. "Your doctor wouldn't have suggested ECT if they didn't think it would help you." This response shifts the responsibility to the doctor and does not address the client's fears.
Correct Answer is A
Explanation
- A mastectomy is a surgical procedure that involves the removal of all or part of the breast, usually to treat breast cancer. A mastectomy can have a significant impact on a woman's physical, emotional, and psychological well-being, as it may affect her body image, self-esteem, sexuality, and identity.
- A mastectomy incision is the wound that results from the surgery, which may vary in size, shape, and location depending on the type and extent of the mastectomy. The incision may be closed with stitches, staples, or glue, and covered with a dressing or bandage.
- The first dressing change is usually done within 24 to 48 hours after the surgery, and it involves removing the old dressing, inspecting the incision for any signs of infection or complications, cleaning the wound, applying a new dressing, and educating the client about wound care .
- When the practical nurse (PN) tells the client that her mastectomy incision is healing well, but the client refuses to look at the incision and refuses to talk about it, this may indicate that the client is experiencing denial, fear, anger, grief, or depression due to the loss of her breast. These are normal and common reactions that may occur at different stages of the recovery process .
- The best response by the PN to the client's silence is to acknowledge and respect the client's feelings, provide support and reassurance, and offer assistance when needed. This will help to establish trust and rapport with the client, as well as promote her coping and adjustment .
- Therefore, option A is the best answer, as it shows empathy and respect for the client's feelings, while also informing the client that the PN will be available when she is ready to look or talk about the mastectomy. Option A also implies that the PN will not pressure or force the client to do something that she is not comfortable with.
- Options B, C, and D are incorrect answers, as they do not show empathy or respect for the client's
feelings, and they may cause more harm than good.
Option B is incorrect because asking another nurse to be present may not address the client's reluctance or
anxiety about looking at her incision.
Option C is incorrect because telling the client that part of recovery is accepting her new body image may
sound insensitive or judgmental, and it may not reflect the client's readiness or willingness to do so.
Option D is incorrect because telling the client that she will feel beter when she sees that the incision is not as bad as she may think may minimize or invalidate the client's feelings, and it may not be true or helpful.
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