While assessing the newborn, the nurse should be aware that the average expected apical pulse range of a full-term, quiet, alert newborn is __ beats/min.
100 to 120
120 to 160
80 to 100
150 to 180
The Correct Answer is B
Choice a) 100 to 120 is incorrect because this is too low for a normal newborn's heart rate. The heart rate of a newborn is influenced by factors such as gestational age, activity level, temperature, and health status. A full-term, quiet, alert newborn should have a heart rate between 120 and 160 beats per minute, which reflects their high metabolic rate and oxygen demand. A heart rate below 100 beats per minute may indicate bradycardia, which can be caused by hypoxia, hypothermia, or cardiac problems.
Choice b) 120 to 160 is correct because this is the normal range for a full-term, quiet, alert newborn's heart rate. The apical pulse is the best way to measure the heart rate of a newborn, as it reflects the actual contractions of the heart. The apical pulse can be auscultated at the fourth intercostal space on the left side of the chest, just below the nipple line. The nurse should count the apical pulse for a full minute, as it may vary with the respiratory cycle.
Choice c) 80 to 100 is incorrect because this is also too low for a normal newborn's heart rate. A full-term, quiet, alert newborn should have a heart rate between 120 and 160 beats per minute, which is higher than that of an adult or an older child. A heart rate below 100 beats per minute may indicate bradycardia, which can be caused by hypoxia, hypothermia, or cardiac problems.
Choice d) 150 to 180 is incorrect because this is too high for a normal newborn's heart rate. A full-term, quiet, alert newborn should have a heart rate between 120 and 160 beats per minute, which is lower than that of a preterm or a crying newborn. A heart rate above 160 beats per minute may indicate tachycardia, which can be caused by fever, infection, anemia, or hyperthyroidism.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice a) They are born before 38 weeks of gestation is incorrect because this is not the definition of SGA. SGA refers to newborns who have a birth weight or length that is significantly lower than expected for their gestational age, regardless of when they are born. Therefore, a newborn can be SGA even if they are born at term or post-term.
Choice b) Placental malfunction is the only recognized cause of this condition is incorrect because this is not the only factor that can contribute to SGA. Placental malfunction can cause fetal growth restriction due to insufficient blood supply and nutrients to the fetus, but there are other possible causes such as maternal factors (e.g.,
hypertension, diabetes, smoking, malnutrition), fetal factors (e.g., chromosomal abnormalities, infections, congenital anomalies), and environmental factors (e.g., altitude, pollution, stress).
Choice c) They weigh less than 2500 g is incorrect because this is not the criterion for SGA. SGA is based on the comparison of the newborn's weight or length with the expected values for their gestational age, not on an absolute cutoff. Therefore, a newborn can be SGA even if they weigh more than 2500 g, as long as they are below the 10th percentile for their gestational age.
Choice d) They are below the 10th percentile on gestational growth charts is correct because this is the most commonly used definition of SGA. Gestational growth charts are tools that plot the expected weight or length of a fetus or newborn according to their gestational age and sex. They are based on population data and can vary
depending on the ethnicity and region of origin of the mother and the baby. A newborn who falls below the 10th percentile on these charts is considered SGA, meaning that they have grown less than 90% of their peers .
Correct Answer is B
Explanation
Choice A) Prepare for an emergency cesarean birth is incorrect because this is not a priority or appropriate action for a nurse who is caring for a client who has preeclampsia and is being treated with magnesium sulfate IV.
Preeclampsia is a condition that causes high blood pressure, proteinuria, and edema during pregnancy. It can lead to complications such as eclampsia, which is seizures, or HELLP syndrome, which is hemolysis, elevated liver enzymes, and low platelets. Magnesium sulfate is a medication that helps to prevent or treat seizures in preeclamptic clients by relaxing the muscles and nerves. However, it can also cause side effects such as respiratory depression, hypotension, or loss of reflexes. Preparing for an emergency cesarean birth may be necessary if the client has severe preeclampsia or fetal distress, but it does not address the immediate problem of magnesium toxicity. Therefore, this action should be done only when indicated by the physician and after stabilizing the client's condition.
Choice B) Discontinue the medication infusion is correct because this is a priority and appropriate action for a nurse who is caring for a client who has preeclampsia and is being treated with magnesium sulfate IV. Discontinuing the medication infusion can help to stop or reduce the adverse effects of magnesium sulfate, such as respiratory depression, hypotension, or loss of reflexes. These effects can indicate magnesium toxicity, which is a life-threatening condition that can cause cardiac arrest or coma. The nurse should also notify the physician and prepare to administer calcium gluconate, which is an antidote for magnesium toxicity. Therefore, this action should be done as soon as possible for clients who show signs of magnesium overdose.
Choice C) Place the client in Trendelenburg's position is incorrect because this is not a safe or suitable action for a nurse who is caring for a client who has preeclampsia and is being treated with magnesium sulfate IV.
Trendelenburg's position means lying on the back with the head lower than the feet. It is sometimes used to improve blood flow to the brain or heart in cases of shock or hypotension. However, it can also cause complications such as increased intracranial pressure, decreased lung expansion, aspiration, or acid reflux. Moreover, it does not help to reverse or prevent the side effects of magnesium sulfate, such as respiratory depression, hypotension, or loss of reflexes. Therefore, this action should be avoided or used with caution for clients who are receiving magnesium sulfate IV.
Choice D) Assess maternal blood glucose is incorrect because this is not a relevant or necessary action for a nurse who is caring for a client who has preeclampsia and is being treated with magnesium sulfate IV. Blood glucose is the level of sugar in the blood that provides energy to the cells. It is measured by a blood test or a finger stick test. It can be affected by various factors such as diet, exercise, medication, or pregnancy. Assessing maternal blood glucose may be important for clients who have diabetes or gestational diabetes, which are conditions that cause high blood sugar levels that can harm the mother and the baby. However, it does not relate to preeclampsia or magnesium sulfate, which are conditions that affect blood pressure and nerve function. Therefore, this action should be done only when indicated by the physician and according to the client's history and needs.
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