A nurse is assessing a newborn's heart rate. Which of the following actions should the nurse take?
Assess the apical pulse while the newborn is crying
Palpate the radial pulse for 30 seconds
Listen to the apical pulse while palpating the radial pulse
Auscultate the apical pulse at least 1 min
The Correct Answer is D
- A is incorrect because assessing the apical pulse while the newborn is crying can result in an inaccurate measurement due to increased heart rate and respiratory rate.
- B is incorrect because palpating the radial pulse for 30 seconds is not appropriate for a newborn as it can be difficult to locate and count accurately.
- C is incorrect because listening to the apical pulse while palpating the radial pulse is not necessary for a newborn and can be confusing and time-consuming.
- D is correct because auscultating the apical pulse at least 1 min is the best way to assess a newborn's heart rate as it provides an accurate and reliable measurement.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Wire cutters are not necessary equipment for postoperative care after a thoracotomy with chest tube placement. Wire cutters are used for cutting wires and may be found in orthopedic or surgical trays, but they are not specifically required for thoracotomy care.
Choice B rationale:
A tracheostomy tray is not necessary for postoperative care following a thoracotomy with chest tube placement. Tracheostomy trays contain supplies for managing a tracheostomy, which is a procedure involving the creation of an opening in the neck to help with breathing. This procedure is not related to thoracotomy care.
Choice C rationale:
Montgomery straps are not necessary equipment for postoperative care after a thoracotomy with chest tube placement. Montgomery straps are used to secure dressings or bandages without adhesive tape. They are not typically used in thoracotomy care.
Choice D rationale:
A padded clamp is essential equipment for postoperative care after a thoracotomy with chest tube placement. The clamp is used to temporarily close or occlude the chest tube during transportation or when changing the drainage system. This prevents air from entering the pleural space, maintaining proper suction and preventing complications such as pneumothorax.
Correct Answer is A
Explanation
Choice A rationale:
The nurse should suggest, "Give your son a little gift from his new sister," as a strategy to help the preschool-age son adjust to having a new sibling. This approach involves a small token or gift given from the newborn to the older sibling. It helps create a positive association and fosters a sense of connection and acceptance between the siblings. The gift symbolizes the new baby's arrival and can help the older child feel special and valued during this transition.
Choice B rationale:
While spending alone time with the new sister is important, the statement, "Give your son plenty of 'alone time' with his sister," does not address the initial meeting concerns. Alone time is relevant once the siblings have established a bond, but the initial introduction requires a more structured approach to ensure a smooth transition.
Choice C rationale:
Planning for the son to meet his sister for the first time at home is not the most suitable strategy. Hospitals provide a controlled environment with healthcare professionals available, ensuring the safety and well-being of both the mother and the newborn. The initial meeting should occur in a setting where medical assistance is readily accessible in case of any unforeseen circumstances.
Choice D rationale:
Holding the daughter when the son first meets her is a common and natural practice but does not actively involve the son in the process. Providing a gift from the baby to the older sibling fosters a sense of participation and inclusion, making the older child feel more involved and excited about the new sibling's arrival.
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