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.

Answer and Explanation

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.

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Correct Answer is ["A","B","D"]

Explanation

Choice A rationale:

The normal temperature range for a newborn measured axillary (armpit) is 97.7-99.3°F (36.5- 37.4°C). This is a crucial vital sign to monitor, as any significant deviation from this range could indicate an underlying issue requiring further evaluation.

Choice B rationale:

The newborn's heart rate varies with their activity level. While asleep, it is around 100 bpm, and when awake, it is 120-160 bpm. During crying or agitation, it can go up to 180 bpm.

Monitoring the heart rate is essential, as any abnormal values might indicate cardiac or other health problems.

Choice D rationale:

The normal respiratory rate for a newborn is 30-60 breaths per minute. Respiratory rate is a critical parameter to monitor as rapid or slow breathing could be a sign of respiratory distress or other respiratory conditions.

Choice C rationale:

Blood pressure is not routinely assessed in newborns, as it is challenging to obtain accurate readings due to their small size and physiology. Instead, other vital signs are relied upon for assessment.

Choice E rationale:

The head circumference is not included in the normal vital sign ranges. However, monitoring head circumference is crucial during infancy to track brain growth and development.

A. The newborn with significant bruising from a face presentation. B. The premature newborn. C. The baby born at 41 weeks' gestation. D. The newborn with O+ blood type, born to a mother with O- blood type.

Correct Answer is C

Explanation

Choice A rationale:

(Incorrect) The newborn with significant bruising from a face presentation is at an increased risk of elevated unconjugated bilirubin levels. Bruising can lead to the breakdown of red blood cells, increasing bilirubin production.

Choice B rationale:

(Incorrect) The premature newborn is at a higher risk of elevated unconjugated bilirubin levels. Premature infants often have an underdeveloped liver, which can lead to reduced bilirubin processing and clearance.

Choice C rationale:

(Correct) The baby born at 41 weeks' gestation is at the lowest risk for elevated unconjugated bilirubin levels. By this stage, the baby's liver is more mature, allowing for efficient processing and clearance of bilirubin.

Choice D rationale:

(Incorrect) The newborn with O+ blood type, born to a mother with O- blood type, is at an increased risk of elevated unconjugated bilirubin levels if the baby's blood type is Rh-positive and the mother's is Rh-negative. This situation can lead to Rh incompatibility and hemolytic disease of the newborn, causing higher bilirubin levels.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","B","D"]

Explanation

Which newborn is at the lowest risk for elevated unconjugated bilirubin levels?

Correct Answer is C

Explanation

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