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"]
Explanation
Choice A rationale:
The Moro reflex is a normal finding in newborns, including those born post-term. It is a primitive reflex that should be present and indicates a healthy neurological system.
Choice B rationale:
Vernix, a protective white substance that coats the skin in utero, is typically absent or minimal in post-term newborns due to its decreased production as gestation progresses. Therefore, it would not be expected in a post-term infant.
Choice C rationale:
Lanugo, the fine hair covering a newborn's body, is usually present in greater amounts in preterm infants. By the time a newborn is post-term, lanugo is typically sparse or absent, making it an unlikely finding.
Choice D rationale:
This maneuver assesses the flexibility of the newborn's joints. Post-term infants tend to have reduced flexibility and increased muscle tone, making this maneuver more difficult or restricted in this population.
Correct Answer is ["B","C","D"]
Explanation
Choice A: Warm the bottle in the microwave.
- Rationale: Warming bottles in the microwave is not recommended. Microwaving can cause uneven heating, creating hot spots in the milk or formula that can burn the baby's mouth. Instead, bottles should be warmed by placing them in a container of warm water or using a bottle warmer.
Choice B: Store prepared bottles in the refrigerator.
- Correct
- Rationale: Prepared bottles of formula should be stored in the refrigerator to prevent bacterial growth. Formula should be used within 24 hours of preparation when properly stored in the refrigerator.
Choice C: Discard unused formula in used bottle after 2 hours.
- Correct
- Rationale: Any unused formula that has been in contact with the baby’s mouth should be discarded after 2 hours due to the risk of bacterial contamination. Bacteria from the baby's saliva can grow in the leftover formula.
Choice D: Never prop a bottle.
- Correct
- Rationale: Bottles should never be propped up and left in the baby’s mouth. This practice increases the risk of choking, ear infections, and tooth decay. Caregivers should always hold the bottle and the baby during feedings.
Choice E: Formula is available in three forms.
- Correct
- Rationale: Formula is available in three forms: powdered, concentrated liquid, and ready-to-feed. Parents should be informed of these options so they can choose the most convenient or appropriate form based on their needs.
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