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. Incorrect. The lithotomy position is not appropriate for this procedure, as it can cause discomfort and embarrassment to the client. The nurse should place the client in a left lateral Sims' position with the right knee flexed for better access to the rectum and to reduce pressure on the abdominal organs.

- B. Incorrect. The nurse should avoid eliciting a vagal response, as it can cause bradycardia, hypotension, and syncope in some clients. The nurse should monitor the client's vital signs and stop the procedure if signs of vagal stimulation occur.

- C. Incorrect. Oral bisacodyl is a stimulant laxative that can cause abdominal cramping, diarrhea, and electrolyte imbalance. It is not indicated for fecal impaction, as it can worsen the condition by increasing the bulk and hardness of the stool. The nurse should administer an enema or a stool softener before attempting digital evacuation.

- D. Correct. The nurse should insert a lubricated gloved finger and advance along the rectal wall, breaking up the stool and removing it in small pieces. The nurse should use gentle pressure and avoid injuring the rectal mucosa. The nurse should also explain the procedure to the client and obtain informed consent before performing it.

A. February 1 B. February 8 C. February 15 D. February 22

Correct Answer is C

Explanation

February 15.

A. February 1 is not the correct EDB according to Nägele's rule. Nägele's rule states that to estimate the EDB, subtract three months from the LMP and add seven days and one year. Therefore, May 8 minus three months is February 8, plus seven days is February 15, plus one year is February 15 of the following year.
B. February 8 is not the correct EDB according to Nägele's rule. Nägele's rule states that to estimate the EDB, subtract three months from the LMP and add seven days and one year. Therefore, May 8 minus three months is February 8, plus seven days is February 15, minus seven days is February 8, plus one year is February 8 of the following year.
C. February 15 is the correct EDB according to Nägele's rule. Nägele's rule states that to estimate the EDB, subtract three months from the LMP and add seven days and one year. Therefore, May 8 minus three months is February 8, plus seven days is February 15, plus one year is February 15 of the following year.
D. February 22 is not the correct EDB according to Nägele's rule. Nägele's rule states that to estimate the EDB, subtract three months from the LMP and add seven days and one year. Therefore, May 8 minus three months is February 8, plus seven days is February 15, plus seven days is February 22, plus one year is February 22 of the following year.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a fecal impaction. Which of the following actions should the nurse take when digitally evacuating the stool?

Correct Answer is D

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Correct Answer is C

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