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","D","E","F"]

Explanation

Choice A rationale

Bottles can be put in the dishwasher, boiled, or cleaned with hot soapy water to ensure they are thoroughly sanitized and safe for the infant.

Choice B rationale

Holding the baby in a supine position during feedings is incorrect because it increases the risk of aspiration. The baby should be held in a semi-upright position.

Choice C rationale

Only burping the baby after they have finished the entire feeding is incorrect because it can lead to discomfort and gas buildup. The baby should be burped during and after feedings.

Choice D rationale

Always holding the bottle while feeding and not propping the bottle is correct as it prevents choking and ensures the baby is feeding safely.

Choice E rationale

Keeping the nipple full of formula throughout the feeding is correct as it prevents the baby from swallowing air, which can cause gas and discomfort.

Choice F rationale

Prepared formula can be kept in the refrigerator for 48 hours, ensuring it remains safe and free from bacterial growth.

A. Monitor blood glucose levels frequently. B. Begin phototherapy immediately. C. Initiate early feeding. D. Prepare for a blood transfusion.

Correct Answer is C

Explanation

Choice A rationale

Monitoring blood glucose levels frequently is important for newborns, especially those at risk for hypoglycemia. However, it does not directly prevent jaundice. Jaundice is caused by elevated bilirubin levels, which are not directly related to blood glucose levels.

Choice B rationale

Beginning phototherapy immediately is a treatment for jaundice, not a preventive measure. Phototherapy is used to reduce high bilirubin levels in newborns who already have jaundice.

Choice C rationale

Initiating early feeding is an effective way to prevent jaundice in newborns. Early feeding helps promote regular bowel movements, which aids in the excretion of bilirubin from the body, thereby reducing the risk of jaundice.

Choice D rationale

Preparing for a blood transfusion is a treatment for severe jaundice, not a preventive measure. Blood transfusions are used in cases of extreme hyperbilirubinemia that do not respond to other treatments.

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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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Correct Answer is ["A","D","E","F"]

Explanation

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Correct Answer is C

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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?