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 A
Explanation
Option A. Instruct the client to void, because this reduces the risk of bladder injury during the procedure. The other options are incorrect because they are not necessary or appropriate for a paracentesis.
Option B, position the client on their left side, is incorrect because the client should be positioned upright or semi-Fowler's to allow gravity to assist with fluid drainage.
Option C, insert an IV catheter, is incorrect because an IV catheter is not required for a paracentesis unless the client needs fluid replacement or medication administration.
Option D, prepare the client for moderate (conscious) sedation, is incorrect because a paracentesis is usually performed under local anesthesia and does not require sedation.
Correct Answer is B
Explanation
Choice A reason:
Request a PRN restraint prescription for clients who are aggressive. Using restraints as a PRN (as-needed) intervention for clients who are aggressive is not appropriate. Restraints should only be used as a last resort when all other non-restraint interventions have been unsuccessful in managing the client's behaviour. Restraints should never be used as a means of punishment or control.
Choice B reason:
It is essential to release the restraints periodically to assess the client's condition, skin integrity, and circulation. Restraints should never be left on continuously without regular checks and re-evaluation of the client's need for restraint use.
Choice C reason:
Attach the restraint to the bed's side rails. Restraints should not be attached to the bed's side rails because it can lead to serious injuries if the client attempts to climb over the side rails while restrained. Instead, restraints should be attached to specific restraint ties or straps that are part of the bed frame.
Choice D reason
Document the client's condition every 15 minutes. While it is essential to document the client's condition regularly when restraints are in use, documenting every 15 minutes might not be sufficient for thorough assessment and monitoring. The frequency of documentation should be more frequent, ideally every 2 hours or according to facility policy, and should include the client's physical and mental status, behaviour, skin integrity, and any signs of distress or complications related to the use of restraints.
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