A nurse is collecting data from a newborn and finds an apical pulse of 130/min. Which of the following actions should the nurse take?
Document this as an expected finding.
Call the neonatologist to assess the newborn.
Ask another nurse to verify the heart rate.
Prepare the newborn for transport to the NICU.
The Correct Answer is A
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D"]
Explanation
Choice A rationale:
Respiratory distress is a priority assessment finding that indicates a newborn may be experiencing cold stress. Cold stress can cause the baby's body to burn brown fat to generate heat, leading to increased oxygen demand and respiratory distress as a compensatory mechanism.
Choice B rationale:
Hyperglycemia is not associated with cold stress. Instead, hypoglycemia (low blood sugar) is a concern in newborns experiencing cold stress as they deplete their glucose stores to maintain body temperature.
Choice C rationale:
Metabolic alkalosis is not a priority assessment finding for cold stress. Metabolic acidosis (not listed in the options) can be associated with cold stress due to increased anaerobic metabolism, but it is not one of the provided choices.
Choice D rationale:
Hypoglycemia is a priority assessment finding associated with cold stress. As the baby's body uses glucose to produce heat from burning brown fat, it can lead to a drop in blood sugar levels, which is a significant concern in newborns.
Choice E rationale:
Metabolic acidosis is not listed among the provided choices, but it can be associated with cold stress due to the increased production of lactic acid from anaerobic metabolism when trying to generate heat.
Correct Answer is B
Explanation
Choice A rationale:
Providing a heat source for the newborn is not the purpose of surfactant. Surfactant is a substance produced in the lungs to reduce surface tension and prevent alveolar collapse during expiration. It helps with the exchange of gases, but it does not generate heat.
Choice B rationale:
This is the correct answer. Surfactant plays a crucial role in assisting the alveoli to remain open by reducing surface tension. This, in turn, allows for proper gas exchange, especially of oxygen and carbon dioxide.
Choice C rationale:
Assisting the ductus arteriosus to remain open is not the purpose of surfactant. The ductus arteriosus is a fetal blood vessel that connects the pulmonary artery to the aorta, bypassing the lungs. After birth, it should close on its own, and surfactant does not influence this process.
Choice D rationale:
Providing energy to the newborn is not the purpose of surfactant. Energy for the newborn comes from nutrition, particularly breast milk or formula, and not from surfactant
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