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 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.
Correct Answer is B
Explanation
Choice A rationale
Small for gestational age (SGA) refers to newborns whose birth weight is below the 10th percentile for their gestational age.
Choice B rationale
Appropriate for gestational age (AGA) refers to newborns whose birth weight is between the 10th and 90th percentiles for their gestational age. A newborn weighing 3350 g at 39 weeks gestation falls within this range.
Choice C rationale
Low birth weight is defined as a birth weight of less than 2500 g, which does not apply to this newborn.
Choice D rationale
Large for gestational age (LGA) refers to newborns whose birth weight is above the 90th percentile for their gestational age.