A 2-day-old newborn is asleep, and the nurse assesses the apical ...

[APUS57]

A 2-day-old newborn is asleep, and the nurse assesses the apical pulse to be 88 beats/min. What would be the most appropriate nursing action based on this assessment finding?
 
  1. Call the physician.
  2. Administer oxygen.
  3. Document the finding.
  4. Place the newborn under the radiant warmer.

Question 2

The nurse is preparing for a postpartum home visit. The patient has been home for a week, is breastfeeding, and experienced a third-degree perineal tear after vaginal delivery. The nurse should assess the patient for:
 
  1. Dietary intake of fiber and fluids.
  2. Dietary intake of folic acid and prenatal vitamins.
  3. Return of hemoglobin and hematocrit levels to baseline.
  4. Return of protein and albumin to predelivery levels.

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Answer to Question 1

3
Explanation: 3. An apical pulse rate of 88 beats/min is within the normal range of a sleeping full-term newborn. The average resting heart rate in the first week of life is 110 to 160 beats/min in a healthy full-term newborn but may vary significantly during deep sleep or active awake states. In full-term newborns, the heart rate may drop to a low of 80 to 100 beats/min during deep sleep.

Answer to Question 2

1
Rationale 1: This mother needs to avoid the risk of constipation. She might be hesitant to have a bowel movement due to anticipated pain from the perineal tear, and constipation will decrease the healing of the laceration.
Rationale 2: Dietary intake of prenatal vitamins is important while breastfeeding, but folic acid is more important prior to conception and in the first weeks of pregnancy to prevent neural tube defects.
Rationale 3: It will take several months for the laboratory levels to return to normal.
Rationale 4: It will take several months for the laboratory levels to return to normal.

[APUS57]

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