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 D

Explanation

A. Soft and non-tender breasts are a normal finding in the early postpartum period.
B. A urine output of 3,000 mL in 12 hours is within the normal range.
C. A fundus palpable at the umbilicus may be normal within the first few hours after childbirth.
D. A heart rate of 128/min may indicate a postpartum complication, such as hemorrhage or infection, and requires further assessment.

A. Vernix caseosa B. Erythema toxicum neonatorum C. Harlequin sign D. Acrocyanosis

Correct Answer is D

Explanation

A. Vernix caseosa is a white, cheese-like substance covering the baby's skin.
B. Erythema toxicum neonatorum is a benign rash that appears in the early days of life.
C. Harlequin sign is a transient color change in a newborn, not related to blue hands and feet.
D. Acrocyanosis is a common and temporary condition where the hands and feet may appear blue due to poor peripheral circulation. It is not typically a sign of coldness.

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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

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