A nurse is caring for a newborn and auscultates an apical heart rate of 130/min. Which of the following actions should the nurse take?
Document this as an expected finding.
Call the provider to further assess the newborn.
Prepare the newborn for transport to the NICU.
Ask another nurse to verify the heart rate.
The Correct Answer is A
A. An apical heart rate of 130/min is within the normal range for a newborn and does not require immediate intervention.
B. Contacting the provider is not necessary as the heart rate is within the expected range.
C. Preparing for NICU transport is not warranted based on a heart rate of 130/min.
D. Verifying the heart rate with another nurse is unnecessary for a heart rate within the normal range.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Acrocyanosis is a normal finding in newborns and does not require immediate intervention.
B. Not passing meconium within the first 24 hours is not uncommon and may be normal.
C. Persistent tachycardia in a newborn, especially with a heart rate of 180 bpm, requires immediate intervention as it may indicate a cardiac or other medical issue.
D. Not voiding within the first 24 hours may be normal, but it should be monitored.
Correct Answer is A
Explanation
A. The presence of lochia rubra with small clots in the immediate postpartum period is expected. The firm and midline fundus indicates appropriate uterine contraction. Continued monitoring is appropriate.
B. Encouraging the client to empty her bladder is a valid intervention, but it is not the priority in this situation.
C. Increasing the frequency of fundal massage is unnecessary, as the fundus is already firm.
D. Notifying the provider is not necessary based on the described findings, as they are within the expected range.
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