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.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is B
Explanation
Choice A rationale
Shivering is not a primary concern for newborns as they have limited ability to shiver. Instead, they rely on non-shivering thermogenesis to maintain body temperature.
Choice B rationale
Cold stress is a significant concern for newborns as it can lead to hypothermia, increased oxygen consumption, and metabolic acidosis. Placing a newborn under a radiant heat warmer helps maintain their body temperature and prevent cold stress.
Choice C rationale
Brown fat production is a natural process in newborns that helps generate heat. However, the primary purpose of using a radiant heat warmer is to prevent cold stress, not to stimulate brown fat production.
Choice D rationale
Basal metabolic rate reduction is not the primary concern. The focus is on preventing cold stress and maintaining the newborn’s body temperature.
Correct Answer is B
Explanation
Choice A rationale
Erythema toxicum is a common, benign rash in newborns but does not cause swelling that crosses suture lines.
Choice B rationale
A caput succedaneum is swelling of the scalp that crosses suture lines and is caused by prolonged pressure on the head during delivery.
Choice C rationale
Mongolian spots are benign, flat, congenital birthmarks with wavy borders and irregular shapes, typically found on the lower back and buttocks, not the head.
Choice D rationale
A cephalhematoma is a collection of blood between the skull bone and its periosteum that does not cross suture lines. .