The nurse is caring for an infant in the NICU. While taking vital ...

[NguyenJ]

The nurse is caring for an infant in the NICU. While taking vital signs, the nurse finds that the baby's heart rate is 195 . The nurse calls the physician, knowing that the normal heart rate should be:
 
  a. 60 to 100 beats per minute.
  b. 100 to 160 beats per minute.
  c. 90 to 140 beats per minute.
  d. 220 beats per minute or higher.

Question 2

When teaching caregivers the correct procedure for maintaining body alignment, the nurse instructs them to:
 
  A. Have a shorter client use a footstool when sitting
  B. Turn the client every 8 to 12 hours while he or she is in bed
  C. Have the client flex the spine while lying on his or her side in bed
  D. Keep the client's popliteal space pressed firmly against the edge of the chair while he or she is sitting up

[allisonblackmore]

Answer to Question 1

B
The infant's heart rate at birth ranges from 100 to 160 beats per minute at rest. By adolescence, the heart rate varies between 60 and 100 beats per minute and remains so throughout adulthood. By age 2, the pulse rate slows to 90 to 140 beats per minute.

Answer to Question 2

A
A. Shorter clients should be taught to use a footstool when sitting.
B. Clients must be repositioned at least every 1 to 2 hours.
C. While lying, vertebral column should be in alignment without observable curves. Allows for even distribution of body weight.
D. While sitting, a 2.5- to 5-cm (1- to 2-inch) space is maintained between edge of seat and popliteal space on posterior surface of knee to ensure that no excessive pressure is placed on popliteal artery or nerve, which could decrease circulation or impair nerve function.