A nurse is collecting data from a newborn 1 hr after delivery. Which of the following respiratory rates is within the expected reference range for a newborn?

Choice A rationale:

An apical pulse of 130/min in a newborn is within the normal range. The normal heart rate for a newborn is generally between 110 to 160 beats per minute (bpm). As the newborn's heart rate falls within this range, the nurse should document it as an expected finding and continue routine monitoring.

Choice B rationale:

Calling the neonatologist to assess the newborn for an apical pulse of 130/min is not warranted as it is a normal finding. The nurse should only notify the neonatologist if there are abnormal vital signs or concerning clinical signs.

Choice C rationale:

Asking another nurse to verify the heart rate is unnecessary in this scenario. The nurse can independently measure the apical pulse and document the finding as long as it falls within the normal range for newborns.

Choice D rationale:

Preparing the newborn for transport to the Neonatal Intensive Care Unit (NICU) is not indicated for a normal apical pulse rate. Transporting a newborn to the NICU is typically reserved for critical or unstable conditions. In this case, the normal heart rate of 130/min does not warrant NICU transport.

Choice A rationale:

Newborns do not show interest in eating while crying. Crying is usually an indication of distress or hunger and not a state where they are interested in eating.

Choice B rationale:

Newborns are most interested in eating when they are in an "alert”. state. During this state, the baby is awake, calm, and attentive, making it an ideal time for feeding.

Choice C rationale:

In the "drowsy”. state, newborns may be sleepy and less interested in eating. They might feed less effectively in this state.

Choice D rationale:

"Active alert”. is a state where the newborn is awake, attentive, and active. While they may be interested in their surroundings, they may also be easily distracted during feeding.