Question

The nurse assesses an apical pulse on an 8lb 4oz newborn infant. The nurse takes which action?

a) Continue monitoring the apical pulse
b) Check the radial pulse instead
c) Notify the healthcare provider
d) Perform a full cardiac assessment

Answer 1

The nurse should continue monitoring the apical pulse as it is part of the standard Apgar test procedure, which assesses a newborn's initial condition and transition to the outside environment.

Step-by-step explanation:

The nurse assesses an apical pulse on an 8lb 4oz newborn infant. Given that the apical pulse is a standard assessment for newborns, the nurse should Continue monitoring the apical pulse. This is a routine part of the Apgar test, which is a quick, easy, and painless assessment used to evaluate a newborn's transition from the uterus to the outside world. Monitoring continues as part of the Apgar scoring system, which includes five criteria: appearance, pulse, grimace, activity, and respiration. These are scored at one minute and five minutes after birth. The heart rate is a critical component and the apical pulse provides the most accurate measurement for infants. If the pulse was abnormal or there were other signs of distress, then the other options might be considered.