A nursery nurse is admitting a neonate and is performing the neonatal assessment.
The apical pulse is auscultated with a rate of 124 bpm, after one full minute of listening.
What is the next appropriate action should the nurse take?

Ask another nurse to verify the heart rate as this is an abnormal finding.

Call the provider and request they come to the hospital immediately for this abnormal finding to further assess the neonate.

Prepare the newborn for transport to the NICU for further cardiac observation.

Document the expected finding.

Answer and Explanation

The Correct Answer is D

Choice A rationale

An apical pulse rate of 124 bpm is within the normal range for a neonate (110-160 bpm). There is no need to ask another nurse to verify the heart rate as it is not an abnormal finding.

Choice B rationale

Calling the provider for an apical pulse rate of 124 bpm is unnecessary as it is within the normal range for a neonate. This action would be appropriate if the heart rate were significantly outside the normal range.

Choice C rationale

Preparing the newborn for transport to the NICU for an apical pulse rate of 124 bpm is not warranted. The heart rate is within the normal range, and there is no indication for further cardiac observation.

Choice D rationale

Documenting the expected finding is the appropriate action. An apical pulse rate of 124 bpm is within the normal range for a neonate, and no further action is needed.

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Correct Answer is []

Explanation

Hyperbilirubinemia

Symptoms: The neonate does show signs of jaundice (yellowish skin), which is a symptom of hyperbilirubinemia. However, the primary concern here is thelow blood glucose level (30 mg/dL), which is more immediately life-threatening and needs urgent attention.
Diagnostic Results: The total serum bilirubin level is 5 mg/dL, which is elevated but not critically high. Hyperbilirubinemia might be a secondary concern, but the immediate symptoms and diagnostic results point more towards hypoglycemia.

Neonatal Abstinence Syndrome (NAS)

Symptoms: NAS typically occurs in newborns exposed to addictive substances in utero, leading to withdrawal symptoms after birth. Common symptoms include irritability, high-pitched crying, tremors, and feeding difficulties.
History: There is no mention of maternal substance use or withdrawal symptoms like frequent yawning or irritability. The jitteriness and poor feeding could overlap with NAS, but the history of gestational diabetes and the low blood glucose level make hypoglycemia a more likely diagnosis.

Summary

Hypoglycemia: The neonate’s symptoms (jitteriness, lethargy, poor feeding) and the critically low blood glucose level (30 mg/dL) strongly indicate hypoglycemia. This condition is common in infants of diabetic mothers and large-for-gestational-age infants.

A. Wipe the cord daily with alcohol prep pads. B. Keep the cord moist. C. Fold the top of the diaper underneath the cord. D. Apply petroleum jelly to the cord stump.

Correct Answer is C

Explanation

Choice A rationale

Wiping the cord daily with alcohol prep pads is not recommended. Current guidelines suggest keeping the cord clean and dry without the use of alcohol, as it can delay the natural drying and falling off process.

Choice B rationale

Keeping the cord moist is not recommended. The cord should be kept dry to promote natural drying and separation. Moisture can increase the risk of infection.

Choice C rationale

Folding the top of the diaper underneath the cord is recommended to keep the cord exposed to air and prevent irritation from urine or stool. This helps the cord dry out and fall off naturally.

Choice D rationale

Applying petroleum jelly to the cord stump is not recommended. The cord should be kept dry, and the use of ointments or creams can interfere with the natural drying process. .

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A nursery nurse is admitting a neonate and is performing the neonatal assessment.The apical pulse is auscultated with a rate of 124 bpm, after one full minute of listening.What is the next appropriate action should the nurse take?

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Correct Answer is []

Explanation

A nurse is teaching a newborn’s parent to care for the umbilical cord stump.Which of the following instructions should the nurse include?

Correct Answer is C

Explanation

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A nursery nurse is admitting a neonate and is performing the neonatal assessment.
The apical pulse is auscultated with a rate of 124 bpm, after one full minute of listening.
What is the next appropriate action should the nurse take?