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 A

Explanation

A. Expressing dissatisfaction with the baby's appearance may indicate a lack of immediate bonding.
B. Noting physical features shared with the father suggests recognition and connection.
C. Declining a baby bath demonstration doesn't necessarily indicate a lack of attachment.
D. Requesting nursery care for sleep doesn't necessarily indicate a lack of attachment.

A. Lancet should penetrate the ball of the foot. B. Lancet should penetrate at the outer aspect of the heel. C. Lancet should penetrate the area just below the fifth toe. D. Lancet should penetrate the walking surface of the heel.

Correct Answer is B

Explanation

A. The ball of the foot is not recommended for heelstick procedures.
B. The outer aspect of the heel is the preferred site. This area has fewer nerve endings and less risk of damaging the bone or cartilage.
C. The area below the fifth toe is not a standard site for a heelstick.
D. The walking surface of the heel should be avoided since it is prone to infection, more sensitive, and may interfere with walking.

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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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Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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