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 D

Explanation

Choice A rationale

The xiphoid process is not the correct anatomical landmark for measuring chest circumference in newborns. It is located at the lower end of the sternum and does not provide a consistent measurement point.

Choice B rationale

The fifth intercostal space is not used for measuring chest circumference in newborns. This space is located between the ribs and is not a reliable landmark for consistent measurements.

Choice C rationale

The sternal notch is not the correct landmark for measuring chest circumference. It is located at the top of the sternum and does not provide a consistent measurement point.

Choice D rationale

The nipple line is the correct anatomical landmark for measuring chest circumference in newborns. This method ensures that the measurement is taken at a consistent and reproducible location, providing an accurate assessment of the chest size relative to growth and development standards.

A. Faint red marks on the plantar surface. B. Copious vernix. C. Dry, cracked skin. D. Scant scalp hair.

Correct Answer is C

Explanation

Choice A rationale

Faint red marks on the plantar surface are more common in preterm infants and are not typically seen in post-term infants.

Choice B rationale

Copious vernix is usually seen in preterm infants. Post-term infants often have little to no vernix.

Choice C rationale

Dry, cracked skin is a common finding in post-term infants due to prolonged exposure to the amniotic fluid.

Choice D rationale

Scant scalp hair is more common in preterm infants. Post-term infants usually have more developed hair.

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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?

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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?