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.
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
Explanation
Choice A rationale
Given the neonate’s symptoms and critically low blood glucose level (30 mg/dL), the most urgent action is to address the hypoglycemia. Therefore, the nurse shouldadminister a bolus of intravenous glucose (Option A). This immediate intervention is crucial to stabilize the neonate and prevent further complications associated with hypoglycemia.
Choice B rationale
While monitoring blood glucose levels is important, waiting 30 minutes to reassess without immediate intervention could allow the hypoglycemia to worsen, potentially leading to severe complications such as seizures or brain damage. Immediate treatment is necessary to stabilize the neonate.
Choice C rationale
Although feeding can help increase blood glucose levels, the neonate’s current symptoms (jitteriness, poor feeding, weak cry, and irritability) suggest that they may not be able to effectively feed. Additionally, the blood glucose level is critically low and requires more rapid correction than feeding alone can provide.
Choice D rationale
While maintaining an appropriate body temperature is important, the neonate’s temperature (36.1°C) is not critically low. The primary concern here is the hypoglycemia, which needs to be addressed immediately. Placing the neonate under a radiant warmer does not directly address the low blood glucose level.
Correct Answer is C
Explanation
Choice A rationale
Depressed fontanelles are not exclusive to premature newborns. They can occur in both premature and full-term infants and are not an indicator of prematurity.
Choice B rationale
Depressed fontanelles do not indicate infection. Infections in newborns typically present with other symptoms such as fever, irritability, and poor feeding.
Choice C rationale
Depressed fontanelles are a sign of dehydration in newborns. When a newborn is dehydrated, the fontanelles can appear sunken due to the lack of fluid in the body.
Choice D rationale
Depressed fontanelles are not a normal finding in newborns. Normally, fontanelles should be flat or slightly curved inward. A depressed fontanelle is a clinical sign that requires further evaluation and intervention.