A nurse is caring for a newborn and hears an apical heart rate of 130/min. What should the nurse do next?

Choice A rationale
Depressed fontanels are not typically associated with increased intracranial pressure (ICP) in infants. In fact, bulging fontanels may be a sign of increased ICP1516.
Choice B rationale
A brisk pupillary reaction to light is not a specific sign of increased ICP in infants. Changes in pupillary reaction can occur in various conditions and are not definitive indicators of increased ICP.
Choice C rationale
Increased sleeping is a symptom of increased ICP in infants. However, this symptom alone is not enough to diagnose increased ICP as it can be seen in other conditions as well.
Choice D rationale
Unspecified symptom is not a valid choice as it does not provide a specific symptom to evaluate.

Choice A rationale
The nurse should be concerned about a client with an 18kg (4 lb) weight gain in her first trimester. This is because the expected weight gain for a client in the first trimester is usually around 1.8 kg (4 lb)1. A weight gain of 18 kg in the first trimester significantly exceeds this expectation, which could indicate a potential health issue such as gestational diabetes or multiple pregnancies. It’s important for the nurse to report this finding to the healthcare provider for further evaluation and management.
Choice B rationale
A client with a 68 kg (15 lb) weight gain in her second trimester does not necessarily pose a concern. Weight gain during pregnancy varies among individuals and can be influenced by factors such as the mother’s body mass index (BMI) before pregnancy, the baby’s growth rate, and the mother’s diet and lifestyle. However, it’s always important to monitor weight gain throughout pregnancy to ensure it’s within a healthy range.
Choice C rationale
A client with a 13 kg (25 lb) weight gain in her third trimester does not necessarily pose a concern. Weight gain during the third trimester can be influenced by factors such as the baby’s growth rate, amniotic fluid volume, and the mother’s increased blood volume. However, it’s always important to monitor weight gain throughout pregnancy to ensure it’s within a healthy range.
Choice D rationale
A client with a 3.6 kg (8 lb) weight gain in her first trimester does not necessarily pose a concern. This is within the expected weight gain range for the first trimester. However, it’s always important to monitor weight gain throughout pregnancy to ensure it’s within a healthy range.