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A nurse is caring for a newborn and hears an apical heart rate of 130/min. What should the nurse do next?

A.

Document this as an expected finding.

B.

Call the provider to further assess the newborn.

C.

Prepare the newborn for transport to the NICU.

D.

Ask another nurse to verify the heart rate.

Answer and Explanation

The Correct Answer is A

Choice A rationale
A newborn’s heart rate normally varies between 120 and 160 beats per minute, but it can rise to 180 beats per minute when the infant is crying or drop as low as 80 to 90 beats per minute when in deep sleep. Therefore, an apical heart rate of 130/min is within the normal range for a newborn.
Choice B rationale
There is no need to call the provider for further assessment if the newborn’s heart rate is within the normal range.
Choice C rationale 
Preparing the newborn for transport to the NICU is not necessary if the heart rate is within the normal range.
Choice D rationale
Asking another nurse to verify the heart rate is not necessary if the heart rate is within the normal range.
 


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Related Questions

Correct Answer is B

Explanation

Choice A rationale
Maternal bradycardia refers to a slower than normal heart rate in the mother. While it can affect the baby’s health, it doesn’t cause late decelerations on the fetal monitor.
Choice B rationale
Late decelerations are caused by uteroplacental insufficiency, which is a decrease in the blood flow to the placenta that reduces the amount of oxygen and nutrients transferred to the fetus. This is why the nurse would interpret late decelerations as indicating uteroplacental insufficiency.
Choice C rationale
Umbilical cord compression can cause variable decelerations, not late decelerations. Variable decelerations are abrupt decreases in the fetal heart rate, typically associated with contractions, and they vary in onset, depth, and duration.
Choice D rationale
Fetal head compression typically causes early decelerations, not late decelerations. Early decelerations are a mirror image of the contraction and are generally not a concern.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"}}

Explanation

  1. WBC count: This finding is not consistent with either sickle cell anemia or hemophilia. Both conditions do not typically cause an increase in white blood cell count.
  2. Temperature: This finding is not consistent with either sickle cell anemia or hemophilia. Neither condition is associated with an elevated body temperature unless there is a concurrent infection.
  3. Bleeding: This finding is consistent with hemophilia. Hemophilia is a bleeding disorder where the blood does not clot properly. This can lead to spontaneous bleeding as well as bleeding following injuries or surgery.
  4. Reported pain: This finding is consistent with sickle cell anemia. Sickle cell anemia can cause episodes of pain when sickle-shaped red blood cells block blood flow through tiny blood vessels to your chest, abdomen and joints. Pain can also occur in your bones.

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