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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. While visual attention to the speaker is a positive sign, routine hearing screenings provide a more accurate assessment of hearing.
B. Routine hearing screenings are conducted on newborns to identify hearing issues early, allowing for intervention if necessary.
C. While most forms of hearing loss may not be inherited, it's important to assess the newborn's hearing through appropriate screenings.
D. Startle reflex is not a reliable indicator of hearing ability, and routine screenings provide more accurate information.

A. Change the perineal pad of a client who just transferred from labor and delivery. B. Monitor vital signs during admission of a client who has gestational hypertension. C. Provide a sitz bath to a client who has a fourth-degree laceration and is 2 days postpartum. D. Observe an area of redness on the breast of a client who is 1 day postpartum.

Correct Answer is C

Explanation

A. Changing the perineal pad of a client who has just been transferred from the labor ward is a task that should not be delegated to an assistive personnel (AP) since it is beyond their scope.
B. Monitoring vital signs during the admission of a client with gestational hypertension requires nursing judgment and assessment skills.
C. Providing a sitz bath to a client with a fourth-degree laceration and is 2 days post- partum can be delegated to an AP. This task does not require the nurse's clinical judgment or assessment skills, and it can be safely performed by the AP following the nurse's instructions.
D. Observing an area of redness on the breast requires nursing assessment and intervention.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is postpartum. The client tells the nurse that the newborn’s maternal grandmother was born deaf and asks how to tell if her newborn hears well. Which of the following statements should the nurse make?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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