A nurse is caring for a newborn and hears an apical heart rate of 130/min. What should the nurse do next?
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
Choice A rationale
A newborn’s heart rate normally varies between 120 and 160 beats per minute, but it can rise to 180 beats per minute when the infant is crying or drop as low as 80 to 90 beats per minute when in deep sleep. Therefore, an apical heart rate of 130/min is within the normal range for a newborn.
Choice B rationale
There is no need to call the provider for further assessment if the newborn’s heart rate is within the normal range.
Choice C rationale
Preparing the newborn for transport to the NICU is not necessary if the heart rate is within the normal range.
Choice D rationale
Asking another nurse to verify the heart rate is not necessary if the heart rate is within the normal range.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Supporting the casted arm with a firm grasp is important to prevent unnecessary movement and potential discomfort or injury to the child. It also helps in ensuring the correct positioning of the cast.
Choice B rationale
Placing a heated fan at the bedside to facilitate drying is not recommended. Excessive heat can cause discomfort and potential burns to the child. The cast should be allowed to dry naturally.
Choice C rationale
Telling the child that the cast will make their arm feel better can be misleading. While the cast is necessary for healing, it may cause discomfort and itching. It’s important to explain to the child what the cast is for and what to expect.
Choice D rationale
Wrapping the arm of the child’s doll or toy prior to the procedure can help the child understand what is happening and make them feel more comfortable. However, this action alone is not sufficient in preparing to apply a cast to a preschooler’s arm.
Correct Answer is A
Explanation
Choice A rationale
Tetralogy of Fallot is a congenital heart defect that includes four specific heart abnormalities: pulmonic stenosis, ventricular septal defect, overriding aorta, and right ventricular hypertrophy.
Choice B rationale
This choice incorrectly identifies aortic stenosis and atrial septal defect as components of Tetralogy of Fallot. In fact, the condition involves pulmonic stenosis and a ventricular septal defect.
Choice C rationale
This choice incorrectly identifies pulmonary stenosis and aortic hypertrophy as components of Tetralogy of Fallot. In fact, the condition involves pulmonic stenosis and right ventricular hypertrophy.
Choice D rationale
This choice incorrectly identifies aortic stenosis as a component of Tetralogy of Fallot. In fact, the condition involves pulmonic stenosis.
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