A nurse is collecting data from a newborn and finds an apical pulse of 130/min. Which of the following actions should the nurse take?
A.
Document this as an expected finding.
B.
Call the neonatologist to assess the newborn.
C.
Ask another nurse to verify the heart rate.
D.
Prepare the newborn for transport to the NICU.
The Correct Answer and Explanation is:
The correct answer is A. Document this as an expected finding.
Explanation:
In newborns, heart rates can vary significantly due to their physiological characteristics and the various stages of their development. For a healthy newborn, an apical pulse rate between 120 and 160 beats per minute is considered normal. An apical pulse rate of 130 beats per minute falls well within this expected range.
Understanding Normal Newborn Heart Rates:
- Normal Range: For neonates, the normal heart rate at rest typically ranges from 120 to 160 beats per minute. This rate can be influenced by various factors including sleep, activity, and crying.
- Assessment: During routine assessments, a nurse should take into account the newborn’s activity level and comfort. If the newborn is calm, a heart rate within the normal range should not be a cause for concern.
When to be Concerned:
- Bradycardia: If the apical pulse rate falls below 120 beats per minute, this may indicate bradycardia, which could be a sign of underlying issues.
- Tachycardia: If the heart rate exceeds 160 beats per minute persistently, it might suggest tachycardia, potentially related to conditions such as fever, anemia, or dehydration.
Appropriate Actions:
- Documentation: Given that an apical pulse rate of 130 is within the normal range for a newborn, the appropriate action is to document this finding. This reflects standard practice and ensures proper record-keeping.
- Verification: While verification might be necessary if there are unusual findings or symptoms, a rate of 130 bpm alone does not warrant immediate rechecking unless other concerns arise.
- No Immediate Emergency: Transporting the newborn to the NICU or calling the neonatologist is unnecessary unless there are additional symptoms or clinical signs indicating a problem.
In summary, the finding of an apical pulse rate of 130 beats per minute in a newborn is considered normal and does not require further immediate action. The appropriate response is to document this as an expected finding and continue with routine monitoring.