A nursery nurse is admitting a neonate and is performing the neonatal assessment.
The apical pulse is auscultated with a rate of 124 bpm, after one full minute of listening.
What is the next appropriate action should the nurse take?

Ask another nurse to verify the heart rate as this is an abnormal finding.

Call the provider and request they come to the hospital immediately for this abnormal finding to further assess the neonate.

Prepare the newborn for transport to the NICU for further cardiac observation.

Document the expected finding.

Answer and Explanation

The Correct Answer is D

Choice A rationale

An apical pulse rate of 124 bpm is within the normal range for a neonate (110-160 bpm). There is no need to ask another nurse to verify the heart rate as it is not an abnormal finding.

Choice B rationale

Calling the provider for an apical pulse rate of 124 bpm is unnecessary as it is within the normal range for a neonate. This action would be appropriate if the heart rate were significantly outside the normal range.

Choice C rationale

Preparing the newborn for transport to the NICU for an apical pulse rate of 124 bpm is not warranted. The heart rate is within the normal range, and there is no indication for further cardiac observation.

Choice D rationale

Documenting the expected finding is the appropriate action. An apical pulse rate of 124 bpm is within the normal range for a neonate, and no further action is needed.

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Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}

Explanation

“The glans penis will appear red and have a yellow crust as it heals. Do not remove this.”
- Essential: This is a normal part of the healing process.
“Ensure the diaper is really tight to keep the gauze attached to the penis.”
- Contraindicated: The diaper should be loose to avoid pressure on the circumcision site.
“Notify your pediatrician if your baby has not voided in 24 hours.”
- Essential: This could indicate a problem that needs medical attention.
“Coat the glans penis with petroleum jelly and cover with gauze.”
- Essential: This helps prevent the diaper from sticking to the circumcision site and aids in healing.
“Check for bleeding every 4 hours for the first 24 hours and notify your pediatrician if there is bleeding at the circumcision site.”
- Essential: Monitoring for bleeding is crucial to ensure there are no complications.

A. Newborns are born with fully developed immune responses capable of independently fighting infections from birth. B. Newborns have a mature gut microbiome that supports their immune system immediately after birth. C. Newborns rely solely on their innate immune system without any contribution from maternal antibodies. D. Newborns receive passive immunity through the placenta and colostrum, but their own immune system is not fully functional until several months of age.

Correct Answer is D

Explanation

Choice A rationale

Newborns are not born with fully developed immune responses. Their immune system is immature and continues to develop after birth. They rely on maternal antibodies for initial protection.

Choice B rationale

Newborns do not have a mature gut microbiome immediately after birth. The gut microbiome develops over time and is influenced by factors such as breastfeeding and exposure to the environment.

Choice C rationale

Newborns do not rely solely on their innate immune system. They receive passive immunity from maternal antibodies transferred through the placenta and colostrum, which provides initial protection against infections.

Choice D rationale

Newborns receive passive immunity through the placenta and colostrum, but their own immune system is not fully functional until several months of age. This passive immunity helps protect them from infections during the early months of life.

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A nursery nurse is admitting a neonate and is performing the neonatal assessment.The apical pulse is auscultated with a rate of 124 bpm, after one full minute of listening.What is the next appropriate action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}

Explanation

Which of the following statements accurately describes a characteristic of the newborn immune system?

Correct Answer is D

Explanation

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A nursery nurse is admitting a neonate and is performing the neonatal assessment.
The apical pulse is auscultated with a rate of 124 bpm, after one full minute of listening.
What is the next appropriate action should the nurse take?