The nurse is assessing an infant's heart rate who woke up crying for 5 minutes.
The infant's heart rate is 170 beats per minute.
When would it be appropriate for the nurse to reassess the infant's heart rate?
During the next deep sleep cycle.
After the infant is in a quiet alert state.
Immediately.
Two hours later.
The Correct Answer is B
Choice A rationale
During the deep sleep cycle, the infant's heart rate naturally decreases due to the parasympathetic nervous system dominance, potentially giving a falsely low reading that does not reflect the infant's baseline or physiological status when awake. The goal is to obtain a baseline measurement when the infant is in a calm, unstimulated state, not a depressed physiological state like deep sleep.
Choice B rationale
The normal heart rate for a newborn/infant is 110-160 beats per minute. A rate of 170 bpm, while above the normal range, is common during periods of stress, agitation, or crying, reflecting increased sympathetic nervous system activity. The most appropriate time to reassess the rate to obtain a true resting or baseline value is when the infant is calm, such as in a quiet alert state or resting state, allowing the heart rate to return to normal parameters.
Choice C rationale
Reassessing immediately while the infant is still crying and agitated will yield a similar, elevated heart rate, as the physiological response to crying (increased oxygen demand and sympathetic stimulation) will still be active. The elevated heart rate is expected during crying, and immediate reassessment does not allow for resolution of the stressor or return to baseline. The nurse should wait for a calm state.
Choice D rationale
Waiting two hours later to reassess the infant's heart rate is too long, especially if the current elevated rate were indicative of a pathological condition rather than just crying. While the elevated rate is likely due to the crying, the assessment should be completed in a timely manner, but after a short period when the infant has calmed down to ensure an accurate, non-stressed measurement is obtained.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Palpating the fundus to the right of the umbilicus suggests a deviation, which is most often caused by a full bladder pushing the uterus out of its midline position. While the uterus is firm at 48 hours postpartum, its normal location should still be midline, not deviated. A distended bladder interferes with uterine contraction and involution, increasing the risk of postpartum hemorrhage.
Choice B rationale
The fundus is typically no longer palpable at the symphysis pubis until about 9 to 10 days postpartum as the process of involution continues and the uterus descends back into the true pelvis. At 48 hours (2 days) postpartum, the fundus should be much higher, approximately at or near the level of the umbilicus, having descended about 1 to 2 cm per day since delivery.
Choice C rationale
The fundus is located at the umbilicus immediately after delivery and descends at a rate of approximately 1 cm (or one fingerbreadth) per day. Therefore, two centimeters above the umbilicus would be the expected finding immediately after birth or possibly in the first 12 hours postpartum, not at the 48-hour mark, indicating a slower than expected involution.
Choice D rationale
The normal rate of uterine involution is for the fundus to descend about 1 to 2 cm per day following delivery. Since the fundus is typically at the umbilicus (U) or 1 to 2 cm below the umbilicus (U-1 or U-2) within 12 to 24 hours postpartum, finding it at the level of the umbilicus at 48 hours is a common and acceptable finding, representing normal progression. —.
Correct Answer is A
Explanation
Choice A rationale
By 3 weeks (21 days) postpartum, the normal process of uterine involution means the fundus should be entirely descended into the true pelvis. Once it drops below the level of the symphysis pubis, it becomes nonpalpable upon abdominal examination. This finding is the expected and desired outcome of the rapid shrinkage of the uterus following childbirth.
Choice B rationale
A fundus palpated 3 cm above the umbilicus (or any distance above the symphysis pubis) at 3 weeks postpartum is indicative of subinvolution, which is an abnormal finding. The fundus typically descends approximately 1 cm, or one finger breadth, per day and should be nonpalpable abdominally by 10 to 14 days.
Choice C rationale
The progression of lochia after 3 weeks should be moving toward lochia alba (white/yellowish-white) or possibly lochia serosa (pinkish-brown), not moderate bright red lochial flow (lochia rubra). The presence of moderate lochia rubra this late is a sign of abnormal involution or retained placental fragments, warranting further assessment.
Choice D rationale
The uterus is typically palpated halfway between the umbilicus and symphysis pubis around the 5th to 6th day postpartum. Finding the uterus at this location at 3 weeks postpartum indicates a significant delay in the normal involution process (subinvolution) and is therefore an abnormal finding requiring intervention.
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