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 C

Explanation

Fetal circulation continues until after the stress of labor.

Choice A rationale:

Fetal circulation undergoes significant changes at birth. It becomes ineffective as the transition from intrauterine to extrauterine life occurs. The foramen ovale and ductus arteriosus, which allow blood to bypass certain fetal circulatory pathways, close as the baby breathes for the first time.

Choice B rationale:

Fetal circulation does not continue until red blood cells are broken down. Red blood cells in a fetus have a shorter lifespan than those in adults and are continually replaced throughout gestation. However, their breakdown is not the reason for the changes in fetal circulation.

Choice C rationale:

The correct answer. Fetal circulation continues until after the stress of labor. During labor, the baby experiences increased stress and pressure, which helps trigger various physiological changes, including the closure of specific fetal circulatory shunts.

Choice D rationale:

Fetal circulation does not continue until adulthood. As mentioned earlier, the transition from fetal to adult circulation occurs during and after birth, with the closure of specific fetal shunts and the establishment of a fully functional adult circulatory system.

A. The newborn's temperature control mechanism is immature. B. Heat increases the flow of oxygen to the newborn's extremities. C. The newborn has a small body surface for his weight. D. Heat facilitates the drainage of mucus for a premature newborn.

Correct Answer is A

Explanation

Choice A rationale:

Placing the newborn in an incubator is essential because the newborn's temperature control mechanism is immature. Premature infants have an underdeveloped thermoregulatory system, making them susceptible to heat loss and cold stress. An incubator provides a controlled, warm environment to maintain the newborn's body temperature within the normal range (around 36.5°C to 37.5°C or 97.7°F to 99.5°F).

Choice B rationale:

Heat increasing the flow of oxygen to the newborn's extremities is not a valid reason for placing the newborn in an incubator. Oxygenation is primarily influenced by respiratory and circulatory mechanisms, not external heat.

Choice C rationale:

The newborn's small body surface area for his weight is not directly related to the need for an incubator. Premature infants have a higher surface area to weight ratio, making them more prone to heat loss, but this is not the primary reason for using an incubator.

Choice D rationale:

Heat facilitating the drainage of mucus is not a reason for placing the newborn in an incubator. Proper positioning and suctioning are used to manage mucus in premature infants, but incubators are primarily for temperature regulation.

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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?

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Naxlex Comprehensive Predictor Exams

Which statement about fetal circulation is true?

Correct Answer is C

Explanation

A nurse is caring for a newborn who is at 34 weeks of gestation, weighs 1,550 g, and has nasal flaring, intercostal retractions, expiratory grunting, and mild cyanosis. The nurse should place the newborn in an incubator for which of the following reasons?

Correct Answer is A

Explanation

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