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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is ["A","D","E","F"]

Explanation

Choice A rationale

Bottles can be put in the dishwasher, boiled, or cleaned with hot soapy water to ensure they are thoroughly sanitized and safe for the infant.

Choice B rationale

Holding the baby in a supine position during feedings is incorrect because it increases the risk of aspiration. The baby should be held in a semi-upright position.

Choice C rationale

Only burping the baby after they have finished the entire feeding is incorrect because it can lead to discomfort and gas buildup. The baby should be burped during and after feedings.

Choice D rationale

Always holding the bottle while feeding and not propping the bottle is correct as it prevents choking and ensures the baby is feeding safely.

Choice E rationale

Keeping the nipple full of formula throughout the feeding is correct as it prevents the baby from swallowing air, which can cause gas and discomfort.

Choice F rationale

Prepared formula can be kept in the refrigerator for 48 hours, ensuring it remains safe and free from bacterial growth.

A. Hepatitis B vaccine only, administered within 1 hour of birth. B. Hepatitis B vaccine and Hepatitis B immunoglobulin administered within 12 hours of delivery. C. Hepatitis B immunoglobulin (HBIG) only, administered within 12 hours of birth. D. Hepatitis B immunoglobulin (HBIG) within 12 hours, followed by hepatitis B vaccine monthly for 12 months.

Correct Answer is B

Explanation

Choice A rationale

Administering only the Hepatitis B vaccine within 1 hour of birth is not sufficient for a newborn born to a Hepatitis B positive mother. The newborn also needs Hepatitis B immunoglobulin (HBIG) to provide immediate passive immunity.

Choice B rationale

Administering both the Hepatitis B vaccine and Hepatitis B immunoglobulin (HBIG) within 12 hours of delivery is the recommended practice for newborns born to Hepatitis B positive mothers. This provides both active and passive immunity.

Choice C rationale

Administering only Hepatitis B immunoglobulin (HBIG) within 12 hours of birth is not sufficient. The newborn also needs the Hepatitis B vaccine to develop long-term immunity.

Choice D rationale

Administering Hepatitis B immunoglobulin (HBIG) within 12 hours, followed by monthly Hepatitis B vaccines for 12 months, is not the standard practice. The newborn should receive the Hepatitis B vaccine series according to the recommended schedule. .

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing discharge instructions for newborn care.The parents have chosen to formula feed their infant.What should the nurse include in the discharge teaching about bottle feeding? (Select all that apply)

Correct Answer is ["A","D","E","F"]

Explanation

Correct Answer is B

Explanation

The nurse is preparing to teach the postpartum mom about newborn feeding cues.Which of the following behaviors of the infant would be considered early hunger cues? Select all that apply.

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

The nursery nurse is receiving a report on her assigned 4 neonates.Which of the following conditions is high risk for unconjugated bilirubin and jaundice?

A nurse is completing a full assessment of a newborn at 4 hours of life. For each of the assessment findings below, click to specify if this is an expected (normal) newborn finding or an abnormal finding. Note: each column must have at least one response option selected.

A nurse is assessing a newborn 1 hour after birth.Which of the following respiratory rates is within the expected reference range for a newborn?

A nurse is preparing to administer 0.5% Erythromycin ophthalmic ointment to a newborn.Which route and dose should the nurse apply?

A nurse on the labor and delivery unit is caring for a newborn immediately following birth.Which of the following actions by the nurse caring for the newborn reduces heat loss by evaporation?

A nurse is completing a newborn assessment and notes small raised pearly white spots on the nose and chin.This finding is characteristic of which of the following?

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?