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. Prolactin remains elevated in the immediate postpartum period of breastfeeding women to stimulate milk production.
B. Progesterone levels decrease rapidly after childbirth.
C. Estrogen levels decrease in the postpartum period, particularly during breastfeeding.
D. Human Placental Lactogen (HPL) levels decrease after childbirth.

A. Fundus palpable to right of midline B. Less than 2.5 cm of rubra lochia on perineal pad C. Client report of increased thirst D. Client report of frequent uterine contractions

Correct Answer is A

Explanation

A. A fundus palpable to the right of midline may indicate a distended bladder pushing the uterus to the side, and it requires intervention to promote bladder emptying.
B. Less than 2.5 cm of rubra lochia on a perineal pad is a normal finding in the early postpartum period.
C. Increased thirst is not directly indicative of bladder distention.
D. Frequent uterine contractions are expected in the postpartum period and do not necessarily indicate bladder distention.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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