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 ["B","C","E"]
Explanation
Choice A rationale:
The Moro reflex is a normal newborn reflex that is typically present up to about 4 months of age. However, it may not be as pronounced or may disappear in post-term newborns.
Choice B rationale:
Vernix is a waxy, white substance that covers the skin of newborns and is more commonly seen in premature babies. However, it can also be present in post-term newborns, especially in skin folds and creases.
Choice C rationale:
Lanugo refers to the fine, soft hair that covers the body of a developing fetus. Post-term newborns may still have abundant lanugo, especially on their shoulders, back, and forehead.
Choice D rationale:
The heel-to-ear maneuverability is not a typical finding in newborns and is not related to post-term gestation.
Choice E rationale:
Post-term newborns often have dry, cracked, and peeling skin because they have been in the amniotic fluid for an extended period. This finding is characteristic of post-term gestation.
Correct Answer is A
Explanation
Choice A rationale:
30 ml is equal to approximately half an ounce. One ounce is equivalent to 29.57 ml. This conversion is essential in pediatric care, especially when administering medications to infants, as doses are often prescribed in milliliters.
Choice B rationale:
Three ounces is not the correct conversion for 30 ml. Three ounces would be equivalent to approximately 88.71 ml, which is significantly more than 30 ml.
Choice C rationale:
Two ounces is not the correct conversion for 30 ml. Two ounces would be approximately
59.15 ml, which is still more than 30 ml. Choice D rationale:
One ounce is not the correct conversion for 30 ml. As mentioned earlier, one ounce is approximately 29.57 ml, which is slightly less than 30 ml. The correct conversion is half an ounce (approximately 14.79 ml more than 29.57 ml), as stated in Choice A.
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