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

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

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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Correct Answer is B

Explanation

Choice A rationale
While reduced fetal oxygen supply can occur with hypertonic contractions and inadequate uterine relaxation, it’s not the primary adverse effect. The main concern is the impact on the progress of labor.
Choice B rationale
This is the correct answer. Inadequate uterine relaxation between hypertonic contractions can delay cervical dilation, slowing the progress of labor.
Choice C rationale
Prolonged labor is not typically associated with hypertonic contractions and inadequate uterine relaxation. In fact, these conditions can lead to a more rapid labor.
Choice D rationale
Increased maternal stress can occur with any labor complication, but it’s not the primary adverse effect of hypertonic contractions and inadequate uterine relaxation.

A. Constipation B. Pain C. Bradycardia D. High fever

Correct Answer is B

Explanation

Choice A rationale
Constipation is not typically associated with a sickle cell crisis. While it can occur due to dehydration, which can trigger a sickle cell crisis, it is not a primary symptom.
Choice B rationale
Pain is the most common symptom of a sickle cell crisis. When sickle-shaped cells block blood flow in the small blood vessels, it can cause severe pain. This pain can occur anywhere in the body, but it most often occurs in the chest, arms, and legs.
Choice C rationale
Bradycardia is not typically a symptom of a sickle cell crisis. Sickle cell crisis primarily affects the blood vessels and does not directly cause a slow heart rate.
Choice D rationale
While a high fever can occur in individuals with sickle cell disease, especially if there is an underlying infection, it is not a primary symptom of a sickle cell crisis.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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