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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View Related questions
Correct Answer is ["D","F","G","H"]
Explanation
Choice A rationale
Flexion of arms is a normal finding in newborns and does not indicate respiratory distress.
Choice B rationale
Caput succedaneum is a common condition where the scalp swells due to pressure during delivery. It does not indicate respiratory distress.
Choice C rationale
A heart rate of 158 bpm is within the normal range for newborns and does not indicate respiratory distress.
Choice D rationale
A respiratory rate of 66/min is above the normal range (30-60 breaths per minute) and indicates respiratory distress.
Choice E rationale
Acrocyanosis is common in newborns and does not indicate respiratory distress.
Choice F rationale
Subcostal retractions indicate increased work of breathing and are a sign of respiratory distress.
Choice G rationale
Nasal flaring is a sign of respiratory distress as it indicates increased effort to breathe.
Choice H rationale
Grunting is a sign of respiratory distress as it indicates difficulty in maintaining lung expansion.
Correct Answer is D
Explanation
Choice A rationale
Microcephaly is not typically associated with an increased risk of unconjugated bilirubin and jaundice.
Choice B rationale
Polydactyly is a congenital condition involving extra fingers or toes and is not associated with an increased risk of unconjugated bilirubin and jaundice.
Choice C rationale
Caput succedaneum is a condition involving swelling of the scalp in a newborn and is not typically associated with an increased risk of unconjugated bilirubin and jaundice.
Choice D rationale
Cephalohematoma is a collection of blood between a baby’s scalp and the skull bone. It is associated with an increased risk of unconjugated bilirubin and jaundice due to the breakdown of red blood cells in the hematoma. .