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 D
Explanation
A. A respiratory rate of 110/min is too high for a newborn and may indicate respiratory distress.
B. A respiratory rate of 100/min is too high for a newborn and may indicate respiratory distress.
C. A respiratory rate of 22/min is too low for a newborn.
D. A normal respiratory rate for a newborn is between 40 and 60 breaths per minute.
Correct Answer is C
Explanation
A. A hot pack to the perineum can be offered after 24 hours, but not before, as heat can increase bleeding.
B. A warm sitz bath can be offered after 24 hours, but not before, as heat can increase bleeding and infection risk.
C. The nurse should also apply an ice pack to the perineum for 20 minutes every 4 hours to reduce swelling and inflammation.
D. Providing a squeeze bottle of antiseptic solution is more related to perineal hygiene rather than pain relief.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today