A nurse is caring for a newborn and auscultates an apical heart rate of 130/min. Which of the following actions should the nurse take?

Document this as an expected finding.

Call the provider to further assess the newborn.

Prepare the newborn for transport to the NICU.

Ask another nurse to verify the heart rate.

Answer and Explanation

The Correct Answer is A

A.   An apical heart rate of 130/min is within the normal range for a newborn and does not require immediate intervention.
B.   Contacting the provider is not necessary as the heart rate is within the expected range.
C. Preparing for NICU transport is not warranted based on a heart rate of 130/min.
D.   Verifying the heart rate with another nurse is unnecessary for a heart rate within the normal range.

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Correct Answer is A

Explanation

A. The presence of lochia rubra with small clots in the immediate postpartum period is expected. The firm and midline fundus indicates appropriate uterine contraction. Continued monitoring is appropriate.
B. Encouraging the client to empty her bladder is a valid intervention, but it is not the priority in this situation.
C. Increasing the frequency of fundal massage is unnecessary, as the fundus is already firm.
D. Notifying the provider is not necessary based on the described findings, as they are within the expected range.

A. “Wash your hands before touching the newborn" B. "All client identification bands should remain in place until discharge." C. "Do not let anyone remove the infant from your sight while you are in the hospital." D. "Check the identification of staff, and if there is a question of validity, call the nursing station." E. "Send the newborn to nursery to be monitored during the night."

Correct Answer is ["A","B","C","D"]

Explanation

A. Hand hygiene is crucial to prevent the spread of infections to the newborn.

B. Keeping identification bands on ensures proper identification of the newborn.

C. Keeping the infant within sight reduces the risk of abduction.

D. Verifying staff identification enhances security and prevents unauthorized individuals from handling the newborn.
E. Sending the newborn to the nursery at night may compromise the mother-infant bonding and is not a recommended practice.

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A nurse is caring for a newborn and auscultates an apical heart rate of 130/min. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is 1 hr postpartum and observes a large amount of lochia rubra and several small clots on the client’s perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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Correct Answer is ["A","B","C","D"]

Explanation

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