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?

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.

The newborn’s Apgar score is 7.

Step 1: Heart rate of 110/min = 2 points.

Step 2: Slow, weak cry = 1 point.

Step 3: Flexed extremities = 1 point.

Step 4: Cries in response to suctioning of the nares = 2 points.

Step 5: Body pink in color with blue extremities = 1 point. Total Apgar score = 2 + 1 + 1 + 2 + 1 = 7.